Provider Demographics
NPI:1639104078
Name:MARINAC, SUSAN D
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:MARINAC
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 1:4621 E SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-2338
Mailing Address - Country:US
Mailing Address - Phone:218-786-3550
Mailing Address - Fax:218-525-7487
Practice Address - Street 1:4621 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-2338
Practice Address - Country:US
Practice Address - Phone:218-786-3550
Practice Address - Fax:218-525-7487
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2944225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40257000Medicaid