Provider Demographics
NPI:1861034936
Name:SERRITELLI, MICHELE LEE
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LEE
Last Name:SERRITELLI
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 1:45120 ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:KING CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93930-9706
Mailing Address - Country:US
Mailing Address - Phone:831-297-3631
Mailing Address - Fax:
Practice Address - Street 1:641 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:KING CITY
Practice Address - State:CA
Practice Address - Zip Code:93930-3231
Practice Address - Country:US
Practice Address - Phone:831-525-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1366251019101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)