Provider Demographics
NPI:1174062871
Name:BACH, MARINA V
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:V
Last Name:BACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 N COUNTRY CLUB DR APT 1501
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1760
Mailing Address - Country:US
Mailing Address - Phone:954-864-2414
Mailing Address - Fax:
Practice Address - Street 1:3625 N COUNTRY CLUB DR APT 1501
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1760
Practice Address - Country:US
Practice Address - Phone:954-864-2414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL222Q00000XMedicaid