Provider Demographics
NPI:1851419121
Name:SILLA, MARK ANTHONY (LPCC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:SILLA
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 833
Mailing Address - Street 2:
Mailing Address - City:TUCUMCARI
Mailing Address - State:NM
Mailing Address - Zip Code:88401-0833
Mailing Address - Country:US
Mailing Address - Phone:575-708-0033
Mailing Address - Fax:
Practice Address - Street 1:6276 TERRELL DR
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-9547
Practice Address - Country:US
Practice Address - Phone:505-708-0033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM010371101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18851419121Medicaid
NM1851419121Medicare NSC
NM1851419121Medicare Oscar/Certification
NM1851419121Medicare PIN
NM1851419121Medicare UPIN