Healthcare Provider Details

I. General information

NPI: 1609866581
Provider Name (Legal Business Name): MICHAEL CIRILLO PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

469 CHANDLER ST
WORCESTER MA
01602-2529
US

IV. Provider business mailing address

7 KENSINGTON RD
WORCESTER MA
01602-1813
US

V. Phone/Fax

Practice location:
  • Phone: 508-791-3677
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number7497
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: