Provider Demographics
NPI:1134307861
Name:ROMERO, MICHAEL JOHN (LISAC-0659)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHN
Last Name:ROMERO
Suffix:
Gender:M
Credentials:LISAC-0659
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 W SEED FARM RD
Mailing Address - Street 2:NEW BEGINNINGS BUILD
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85247
Mailing Address - Country:US
Mailing Address - Phone:602-528-7167
Mailing Address - Fax:602-528-1374
Practice Address - Street 1:483 W SEED FARM RD
Practice Address - Street 2:NEW BEGINNINGS BUILD
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85247
Practice Address - Country:US
Practice Address - Phone:602-528-7167
Practice Address - Fax:602-528-1374
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-0659101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ346214Medicaid