Healthcare Provider Details

I. General information

NPI: 1891188744
Provider Name (Legal Business Name): MICHAEL PERILLO III BCBA, LBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2015
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14445 POTOMAC MILLS RD STE 8
WOODBRIDGE VA
22192-6807
US

IV. Provider business mailing address

542 AMHERST ST STE B
NASHUA NH
03063-1016
US

V. Phone/Fax

Practice location:
  • Phone: 954-218-6510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-14-17655
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133002119
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA1597
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: