Provider Demographics
NPI:1215905526
Name:WINE, MARILYN ANNE (LPC)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:ANNE
Last Name:WINE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARNE
Other - Middle Name:A
Other - Last Name:WINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:12605 E 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-2545
Mailing Address - Country:US
Mailing Address - Phone:303-493-7000
Mailing Address - Fax:303-465-0604
Practice Address - Street 1:12605 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2545
Practice Address - Country:US
Practice Address - Phone:303-493-7000
Practice Address - Fax:303-465-0604
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1983101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional