Provider Demographics
NPI:1407243074
Name:JORAMO, MARLYS KAY
Entity Type:Individual
Prefix:
First Name:MARLYS
Middle Name:KAY
Last Name:JORAMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 2ND AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8226
Mailing Address - Country:US
Mailing Address - Phone:701-239-6822
Mailing Address - Fax:701-241-5775
Practice Address - Street 1:1010 2ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8226
Practice Address - Country:US
Practice Address - Phone:701-239-6822
Practice Address - Fax:701-241-5775
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2898171M00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND79235Medicaid