Provider Demographics
NPI:1184491714
Name:ROSSILLI, MICHAEL J
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:ROSSILLI
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 1:91 BURBANK AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2318
Mailing Address - Country:US
Mailing Address - Phone:973-886-5091
Mailing Address - Fax:
Practice Address - Street 1:91 BURBANK AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-2318
Practice Address - Country:US
Practice Address - Phone:973-886-5091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC048670001041C0700X
NY24106341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical