Provider Demographics
NPI:1912363441
Name:JOY, MARIENA STAR (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARIENA
Middle Name:STAR
Last Name:JOY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:GAIL
Other - Middle Name:MARIE
Other - Last Name:SMALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:137 HALL AVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-1519
Mailing Address - Country:US
Mailing Address - Phone:541-229-7879
Mailing Address - Fax:
Practice Address - Street 1:137 HALL AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-1519
Practice Address - Country:US
Practice Address - Phone:541-229-7879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2023-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL107671041C0700X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500740402Medicaid
OR500740402Medicaid