Provider Demographics
NPI:1790178218
Name:SERRANO, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SERRANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 ELECTRIC AVE
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-5371
Mailing Address - Country:US
Mailing Address - Phone:978-503-7520
Mailing Address - Fax:
Practice Address - Street 1:507 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-5371
Practice Address - Country:US
Practice Address - Phone:978-503-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303295Medicaid
MA1307576Medicaid
MAM18463OtherBLUE CROSS BLUE SHIELD
MA1303295Medicaid