Provider Demographics
NPI:1841920857
Name:MARESCA, JUSTINE NICOLE
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:NICOLE
Last Name:MARESCA
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 1:700 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:IN
Mailing Address - Zip Code:46304-1861
Mailing Address - Country:US
Mailing Address - Phone:219-510-4156
Mailing Address - Fax:
Practice Address - Street 1:700 WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:IN
Practice Address - Zip Code:46304-1861
Practice Address - Country:US
Practice Address - Phone:219-510-4156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99108823A101YA0400X
IN33011193A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)