Provider Demographics
NPI:1528206588
Name:CHABOLLA, MARINA (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:MARINA
Middle Name:
Last Name:CHABOLLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 E ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-3641
Mailing Address - Country:US
Mailing Address - Phone:602-256-5300
Mailing Address - Fax:602-256-5307
Practice Address - Street 1:1830 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-3641
Practice Address - Country:US
Practice Address - Phone:602-256-5300
Practice Address - Fax:602-256-5307
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11132101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86-0841341OtherFED ID# 86-0841341