Provider Demographics
NPI:1255816708
Name:MARINO, CAROLINE VIEIRA
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:VIEIRA
Last Name:MARINO
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 1:2872 S PINE FLATS WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9140
Mailing Address - Country:US
Mailing Address - Phone:310-210-1664
Mailing Address - Fax:
Practice Address - Street 1:112 9TH AVE S STE B4
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3825
Practice Address - Country:US
Practice Address - Phone:208-261-1076
Practice Address - Fax:208-586-5120
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-01
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6977101YM0800X
IDLCPC-10031101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health