Provider Demographics
NPI:1326261645
Name:RUTKOWSKI, MARINA RENEE (LCSW-C)
Entity Type:Individual
Prefix:MS
First Name:MARINA
Middle Name:RENEE
Last Name:RUTKOWSKI
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:MS
Other - First Name:MARINA
Other - Middle Name:RENEE
Other - Last Name:DANTZLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW-C
Mailing Address - Street 1:903 ADANA RD STE D3
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-4745
Mailing Address - Country:US
Mailing Address - Phone:317-313-0240
Mailing Address - Fax:
Practice Address - Street 1:1009 FREDERICK RD
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-5055
Practice Address - Country:US
Practice Address - Phone:440-467-0648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 20571104100000X
PACW0164491041C0700X
IL1490132951041C0700X
GACSW0046201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD143574400Medicaid