Provider Demographics
NPI:1821766171
Name:CHROIRILUS, CARMELLE VIERGE
Entity Type:Individual
Prefix:MS
First Name:CARMELLE
Middle Name:VIERGE
Last Name:CHROIRILUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17222 133RD AVE APT 10C
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3911
Mailing Address - Country:US
Mailing Address - Phone:516-424-5665
Mailing Address - Fax:
Practice Address - Street 1:17222 133RD AVE APT 10C
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-3911
Practice Address - Country:US
Practice Address - Phone:516-424-5665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1427305201103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2654191Medicaid