Provider Demographics
NPI:1841353331
Name:MARINO, NICOLE (LCSW)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:MARINO
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 1:2630 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-4318
Mailing Address - Country:US
Mailing Address - Phone:704-355-9484
Mailing Address - Fax:704-446-4983
Practice Address - Street 1:2630 E 7TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-4318
Practice Address - Country:US
Practice Address - Phone:704-355-9484
Practice Address - Fax:704-446-4983
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0060001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1841353331Medicaid
SCSW1202Medicaid
NC1841353331Medicaid