Provider Demographics
NPI:1346495215
Name:MARINO, KATHLEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MARINO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CENTER DR
Mailing Address - Street 2:RIVERHEAD MENTAL HEALTH CLINIC, SECOND FLOOR
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-3393
Mailing Address - Country:US
Mailing Address - Phone:631-852-1440
Mailing Address - Fax:
Practice Address - Street 1:300 CENTER DR
Practice Address - Street 2:RIVERHEAD MENTAL HEALTH CLINIC, SECOND FLOOR
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-3393
Practice Address - Country:US
Practice Address - Phone:631-852-1440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR057655-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10410C0700XOtherTAXONOMY # FOR SOCIAL WORKER
NY1104920313OtherRIVERHEAD MH NPI
NY00688179OtherRIVERHEAD MH MEDICAID PROVIDER
NY116000464OtherSUFFOLK COUNTY TAX ID