Provider Demographics
NPI:1962772780
Name:MARINO, ERICA L (PHD INTERN)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:L
Last Name:MARINO
Suffix:
Gender:F
Credentials:PHD INTERN
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:
Other - Last Name:MARINO-BLANCHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3017 W CHARLESTON BLVD STE 54
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3017 W CHARLESTON BLVD STE 54
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1927
Practice Address - Country:US
Practice Address - Phone:702-637-5198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPI039103TA0400X, 103TC2200X, 103TM1800X, 103TH0004X, 103TC0700X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth