Provider Demographics
NPI:1104607498
Name:CARRILLO, ELYDE MARIT (PTA)
Entity type:Individual
Prefix:
First Name:ELYDE
Middle Name:MARIT
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8437 LENNOX ST
Mailing Address - Street 2:
Mailing Address - City:WEST RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99353-5533
Mailing Address - Country:US
Mailing Address - Phone:509-303-0434
Mailing Address - Fax:
Practice Address - Street 1:8819 W VICTORIA AVE # 110
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7193
Practice Address - Country:US
Practice Address - Phone:509-783-1851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60658597225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant