Provider Demographics
NPI:1083482244
Name:CARRILLO, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:CARRILLO
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 1:25 VINE ST APT 14
Mailing Address - Street 2:
Mailing Address - City:LEIPSIC
Mailing Address - State:OH
Mailing Address - Zip Code:45856-2410
Mailing Address - Country:US
Mailing Address - Phone:419-969-0045
Mailing Address - Fax:
Practice Address - Street 1:25 VINE ST APT 14
Practice Address - Street 2:
Practice Address - City:LEIPSIC
Practice Address - State:OH
Practice Address - Zip Code:45856-2410
Practice Address - Country:US
Practice Address - Phone:419-969-0045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid