Provider Demographics
NPI:1750446720
Name:STAGNO, MARILYN J
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:J
Last Name:STAGNO
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 1:6 EAST COVE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-9527
Mailing Address - Country:US
Mailing Address - Phone:847-381-0571
Mailing Address - Fax:
Practice Address - Street 1:6 EAST COVE DRIVE
Practice Address - Street 2:
Practice Address - City:SOUTH BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-9527
Practice Address - Country:US
Practice Address - Phone:847-381-0571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2020-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-005066103TC0700X, 103TF0200X, 103TH0100X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1607281OtherBLUE CROSS & BLUE SHIELD
IL1607281OtherBLUE CROSS & BLUE SHIELD