Provider Demographics
NPI:1992472732
Name:VIRELLA, MARK ANTHONY (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:VIRELLA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 TARRYTOWN RD # 1074
Mailing Address - Street 2:
Mailing Address - City:ELMSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:10523-3417
Mailing Address - Country:US
Mailing Address - Phone:914-372-6272
Mailing Address - Fax:
Practice Address - Street 1:330 S BROADWAY UNIT H12
Practice Address - Street 2:
Practice Address - City:TARRYTOWN
Practice Address - State:NY
Practice Address - Zip Code:10591-5628
Practice Address - Country:US
Practice Address - Phone:347-968-2444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-28
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
089820101YM0800X, 104100000X
NY0898201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty