Basic Information
| Provider Information | |||||||||
| NPI: | 1649625823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARINO | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | RIAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW, LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20816 E 11 MILE RD STE 112 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480811579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865561516 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20816 E 11 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480811565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865561516 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2016 | ||||||||
| LastUpdateDate: | 07/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 4101006682 | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 1041C0700X | 6801098353 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1336610393 | 05 | MI | MEDICAID |