Healthcare Provider Details

I. General information

NPI: 1164974333
Provider Name (Legal Business Name): MIGUEL SILVESTRE PEREZ PORTILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 E DICKENSON PL # 80222
DENVER CO
80222-6012
US

IV. Provider business mailing address

4193 S RICHFIELD WAY
AURORA CO
80013-3227
US

V. Phone/Fax

Practice location:
  • Phone: 303-504-6500
  • Fax: 303-758-5793
Mailing address:
  • Phone: 720-879-7880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: