Provider Demographics
NPI:1467835017
Name:MARINELLO, MACKIE
Entity Type:Individual
Prefix:
First Name:MACKIE
Middle Name:
Last Name:MARINELLO
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 1:1740 NW ARTHUR CIR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1941
Mailing Address - Country:US
Mailing Address - Phone:541-207-7523
Mailing Address - Fax:
Practice Address - Street 1:14645 SW FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-2727
Practice Address - Country:US
Practice Address - Phone:541-207-7523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT09200225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant