MEDICARE: MICHAEL LOUIS VERRILLI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	0127471	NM
2	101YM0800X	Mental Health Counselor	0127461	NM

General Provider Information

NPI Number	:	1548508773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL LOUIS VERRILLI

Provider Business Mailing Address
First Line	:	6004 TIERRA ST NE
Second Line	:	APT. A
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-7035
Country	:	US
Telephone Number	:	551-804-7450
Fax Number	:

Provider Business Practice Location Address
First Line	:	6004 TIERRA ST NE
Second Line	:	APT. A
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-7035
Country	:	US
Telephone Number	:	551-804-7450
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2013
Last Update Date	:	01/23/2013

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