Provider Demographics
NPI:1053427963
Name:MARINO, DONNA M (PSYD)
Entity type:Individual
Prefix:DR
First Name:DONNA
Middle Name:M
Last Name:MARINO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 LAKE ST
Mailing Address - Street 2:STE 310
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1085
Mailing Address - Country:US
Mailing Address - Phone:773-882-0373
Mailing Address - Fax:708-524-8758
Practice Address - Street 1:1101 LAKE ST
Practice Address - Street 2:STE 310
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1085
Practice Address - Country:US
Practice Address - Phone:773-882-0373
Practice Address - Fax:708-524-8758
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006816103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01623882OtherBLUE CROSS BLUE SHIELD