Provider Demographics
NPI:1760657506
Name:DIDENKO, MARINA (LCSW)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:DIDENKO
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 GATEWAY CENTER WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4550
Mailing Address - Country:US
Mailing Address - Phone:619-984-0458
Mailing Address - Fax:
Practice Address - Street 1:995 GATEWAY CENTER WAY STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4550
Practice Address - Country:US
Practice Address - Phone:619-984-0458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0143461041C0700X
CA1281821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149014346Medicaid
ILIL6389001Medicare PIN