Provider Demographics
NPI:1548508773
Name:VERRILLI, MICHAEL LOUIS
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LOUIS
Last Name:VERRILLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6004 TIERRA ST NE
Mailing Address - Street 2:APT. A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-7035
Mailing Address - Country:US
Mailing Address - Phone:551-804-7450
Mailing Address - Fax:
Practice Address - Street 1:6004 TIERRA ST NE
Practice Address - Street 2:APT. A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-7035
Practice Address - Country:US
Practice Address - Phone:551-804-7450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0127471101YA0400X
NM0127461101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)