Basic Information
| Provider Information | |||||||||
| NPI: | 1629625322 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARRILLO | ||||||||
| FirstName: | ITZEL | ||||||||
| MiddleName: | ZELENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128507 W KING TULL RD | ||||||||
| Address2: | |||||||||
| City: | PROSSER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993508600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093030186 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3801 KERN WAY | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989026340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095743200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2019 | ||||||||
| LastUpdateDate: | 08/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.