Provider Demographics
NPI:1649413683
Name:FORTINO, MARIANNE THERESA
Entity type:Individual
Prefix:MRS
First Name:MARIANNE
Middle Name:THERESA
Last Name:FORTINO
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 1:3500 W MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-3308
Mailing Address - Country:US
Mailing Address - Phone:248-203-9760
Mailing Address - Fax:248-203-6690
Practice Address - Street 1:3500 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48301-3308
Practice Address - Country:US
Practice Address - Phone:248-203-9760
Practice Address - Fax:248-203-6690
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000222231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist