Provider Demographics
NPI:1245773472
Name:MARIN, INGRID M (CADC I)
Entity Type:Individual
Prefix:MS
First Name:INGRID
Middle Name:M
Last Name:MARIN
Suffix:
Gender:F
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 LEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2322
Mailing Address - Country:US
Mailing Address - Phone:408-791-9363
Mailing Address - Fax:
Practice Address - Street 1:102 S 11TH ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-2132
Practice Address - Country:US
Practice Address - Phone:408-998-5191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-20
Last Update Date:2016-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI06311016101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)