Provider Demographics
NPI:1942843636
Name:VARGHESE, MARINA SUSAN
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:SUSAN
Last Name:VARGHESE
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 1:48337 AMERICAN ELM DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1429
Mailing Address - Country:US
Mailing Address - Phone:586-925-8299
Mailing Address - Fax:
Practice Address - Street 1:5877 LIVERNOIS RD STE 104
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-3100
Practice Address - Country:US
Practice Address - Phone:734-545-6335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician