Provider Demographics
NPI:1336391663
Name:MARINO, MARY A (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:A
Last Name:MARINO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:ANASTASIOW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1133 BROADWAY STE 807
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-8047
Mailing Address - Country:US
Mailing Address - Phone:917-478-4816
Mailing Address - Fax:212-243-3609
Practice Address - Street 1:1133 BROADWAY STE 807
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-8047
Practice Address - Country:US
Practice Address - Phone:917-478-4816
Practice Address - Fax:212-243-3609
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-17
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY06188103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300082500Medicare PIN