Provider Demographics
NPI:1477041598
Name:MARINE, CAROL ANN
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:MARINE
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:PO BOX 760224
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-0224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17348 W 12 MILE RD STE 106
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-6325
Practice Address - Country:US
Practice Address - Phone:888-492-9386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401002893101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional