Provider Demographics
NPI:1457633703
Name:GARAVAGLIA, MARINA (MSW, LS)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:GARAVAGLIA
Suffix:
Gender:F
Credentials:MSW, LS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 W SHERWIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-2263
Mailing Address - Country:US
Mailing Address - Phone:847-338-7533
Mailing Address - Fax:
Practice Address - Street 1:1205 W SHERWIN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-2263
Practice Address - Country:US
Practice Address - Phone:847-338-7533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health