Provider Demographics
NPI:1417223991
Name:MARINO, CALLIE GORDON (LPCA, NCC)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:GORDON
Last Name:MARINO
Suffix:
Gender:F
Credentials:LPCA, NCC
Other - Prefix:
Other - First Name:CALLIE
Other - Middle Name:ELIZABETH
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCA, NCC
Mailing Address - Street 1:208 E BESSEMER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-6320
Mailing Address - Country:US
Mailing Address - Phone:336-542-2076
Mailing Address - Fax:336-272-1182
Practice Address - Street 1:208 E BESSEMER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-6320
Practice Address - Country:US
Practice Address - Phone:336-542-2076
Practice Address - Fax:336-272-1182
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA9336101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional