Provider Demographics
NPI:1194122879
Name:MARSICANO, TINA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:MARSICANO
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 1:201 MONROE AVE NW STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2212
Mailing Address - Country:US
Mailing Address - Phone:800-600-4096
Mailing Address - Fax:
Practice Address - Street 1:2301 GLADES RD STE 700
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-7397
Practice Address - Country:US
Practice Address - Phone:800-600-4096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY081475-1101YM0800X
FLSW128431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health