Provider Demographics
NPI:1760712954
Name:SHIRILLA, MARIANNE G (MA)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:G
Last Name:SHIRILLA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10379 B DEMOCRACY LANE
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2505
Mailing Address - Country:US
Mailing Address - Phone:703-657-9721
Mailing Address - Fax:703-591-2563
Practice Address - Street 1:10379 B DEMOCRACY LANE
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2505
Practice Address - Country:US
Practice Address - Phone:703-657-9721
Practice Address - Fax:703-591-2563
Is Sole Proprietor?:No
Enumeration Date:2010-01-11
Last Update Date:2021-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717001260106H00000X
VA0701004270101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104429Medicaid