Provider Demographics
NPI:1124350889
Name:CARRILLO, ITZEL (OTR)
Entity type:Individual
Prefix:MRS
First Name:ITZEL
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MRS
Other - First Name:ITZEL
Other - Middle Name:
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:2808 MAGIC ROCK DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-4551
Mailing Address - Country:US
Mailing Address - Phone:915-408-7198
Mailing Address - Fax:
Practice Address - Street 1:1445 BESSEMER DR
Practice Address - Street 2:STE. C
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-5930
Practice Address - Country:US
Practice Address - Phone:915-633-1975
Practice Address - Fax:185-553-3140
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-05
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113411225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287698YNCDMedicare PIN