Provider Demographics
NPI:1811934995
Name:PETTINATI, MARILYN SANDRA (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:SANDRA
Last Name:PETTINATI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38-14 MORLOT AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-4917
Mailing Address - Country:US
Mailing Address - Phone:201-723-9016
Mailing Address - Fax:
Practice Address - Street 1:38-14 MORLOT AVE
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-4917
Practice Address - Country:US
Practice Address - Phone:201-723-9016
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SCOO405700101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJSCO4057NJOtherLICENSED CLINICAL SOCIAL
NJ641877Medicare ID - Type UnspecifiedMEDICARE IDENTIFICATION