Basic Information
Provider Information | |||||||||
NPI: | 1467171587 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARILLO | ||||||||
FirstName: | COURTNEY | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | SUBSTANCE ABUSE ASSO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13 MEADOW HAWK LN | ||||||||
Address2: |   | ||||||||
City: | SILVER CITY | ||||||||
State: | NM | ||||||||
PostalCode: | 880229727 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5753136714 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3200 32ND STREET BYP | ||||||||
Address2: |   | ||||||||
City: | SILVER CITY | ||||||||
State: | NM | ||||||||
PostalCode: | 880617802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5755972650 | ||||||||
FaxNumber: | 5755972651 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2022 | ||||||||
LastUpdateDate: | 08/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CTB-2022-0236 | NM | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.