Basic Information
| Provider Information | |||||||||
| NPI: | 1346495215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARINO | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | L.C.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 CENTER DR | ||||||||
| Address2: | RIVERHEAD MENTAL HEALTH CLINIC, SECOND FLOOR | ||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119013393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318521440 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 CENTER DR | ||||||||
| Address2: | RIVERHEAD MENTAL HEALTH CLINIC, SECOND FLOOR | ||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119013393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318521440 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2008 | ||||||||
| LastUpdateDate: | 11/19/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | PR057655-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 10410C0700X | 01 | NY | TAXONOMY # FOR SOCIAL WORKER | OTHER | 1104920313 | 01 | NY | RIVERHEAD MH NPI | OTHER | 00688179 | 01 | NY | RIVERHEAD MH MEDICAID PROVIDER | OTHER | 116000464 | 01 | NY | SUFFOLK COUNTY TAX ID | OTHER |