Provider Demographics
NPI:1639650609
Name:MARINO, MICHAEL VINCENT
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:VINCENT
Last Name:MARINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SPOTSWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-2476
Mailing Address - Country:US
Mailing Address - Phone:917-818-0297
Mailing Address - Fax:
Practice Address - Street 1:17 SPOTSWOOD AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NJ
Practice Address - Zip Code:08831-2476
Practice Address - Country:US
Practice Address - Phone:917-818-0297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00432800101YM0800X
NJ37PC00755500101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health