Provider Demographics
NPI:1700750791
Name:CARRILLO, MIRANDA CAROLINA
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:CAROLINA
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 1:446 POND VIEW LN
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-4415
Mailing Address - Country:US
Mailing Address - Phone:630-818-6576
Mailing Address - Fax:
Practice Address - Street 1:446 POND VIEW LN
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-4415
Practice Address - Country:US
Practice Address - Phone:630-818-6576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-02
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208.001364106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist