Provider Demographics
NPI:1538415682
Name:MARINO, RUSSELL ANTHONY (MA, LCMHC)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:ANTHONY
Last Name:MARINO
Suffix:
Gender:M
Credentials:MA, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 VILLAGE CIRCLE WAY APT 112
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-6130
Mailing Address - Country:US
Mailing Address - Phone:585-975-9216
Mailing Address - Fax:
Practice Address - Street 1:100 VILLAGE CIRCLE WAY APT 112
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-6130
Practice Address - Country:US
Practice Address - Phone:919-975-9216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA9058101Y00000X, 101YP2500X
101Y00000X
NC9058101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional