Provider Demographics
NPI:1336278399
Name:FINE, MARVIN JERRY (PHD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:JERRY
Last Name:FINE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 NOTT RD
Mailing Address - Street 2:
Mailing Address - City:REXFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12148
Mailing Address - Country:US
Mailing Address - Phone:518-783-1051
Mailing Address - Fax:518-783-1051
Practice Address - Street 1:70 NOTT RD
Practice Address - Street 2:
Practice Address - City:REXFORD
Practice Address - State:NY
Practice Address - Zip Code:12148
Practice Address - Country:US
Practice Address - Phone:518-783-1051
Practice Address - Fax:518-783-1051
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010014103T00000X
NY5732755106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01698604Medicaid
NY01698604Medicaid
R56115Medicare UPIN