Provider Demographics
NPI:1336173301
Name:CARRILLO, JT (LISW)
Entity type:Individual
Prefix:
First Name:JT
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2132A CENTRAL AVE SE # 249
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4083
Mailing Address - Country:US
Mailing Address - Phone:505-259-7769
Mailing Address - Fax:
Practice Address - Street 1:2132A CENTRAL AVE SE # 249
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4083
Practice Address - Country:US
Practice Address - Phone:505-259-7769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-048911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical