Provider Demographics
NPI:1427392745
Name:MARIN, GRACE (MS)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MARIN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12939 CRAGSIDE LN
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-6662
Mailing Address - Country:US
Mailing Address - Phone:407-968-8823
Mailing Address - Fax:
Practice Address - Street 1:12939 CRAGSIDE LN
Practice Address - Street 2:
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-6662
Practice Address - Country:US
Practice Address - Phone:407-968-8823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH13220101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health