Provider Demographics
NPI:1518438597
Name:MARINO, CARISSA ROSE
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:ROSE
Last Name:MARINO
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 1:8112 MARGARET PL
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-8045
Mailing Address - Country:US
Mailing Address - Phone:718-872-8666
Mailing Address - Fax:
Practice Address - Street 1:5920 VAN DOREN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-4018
Practice Address - Country:US
Practice Address - Phone:718-592-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist