Provider Demographics
NPI:1477896223
Name:MARINO, ANGELA (MT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MARINO
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W ELLISON ST
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-4246
Mailing Address - Country:US
Mailing Address - Phone:817-933-8556
Mailing Address - Fax:
Practice Address - Street 1:1125 BLACKBIRD CT
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-0602
Practice Address - Country:US
Practice Address - Phone:817-295-2484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-30
Last Update Date:2013-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT112594225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist