Provider Demographics
NPI:1851636104
Name:CHRISTINE A MARRA PSYCHOLOGIST PLLC
Entity Type:Organization
Organization Name:CHRISTINE A MARRA PSYCHOLOGIST PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARRA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:518-587-0499
Mailing Address - Street 1:55 S ANGELL ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5206
Mailing Address - Country:US
Mailing Address - Phone:518-587-0499
Mailing Address - Fax:518-786-6467
Practice Address - Street 1:1 MARCUS BLVD
Practice Address - Street 2:STE. 105
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-5953
Practice Address - Country:US
Practice Address - Phone:518-587-0499
Practice Address - Fax:518-786-6467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-27
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014506-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ100083126Medicare PIN