Basic Information
| Provider Information | |||||||||
| NPI: | 1659949410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRILLO | ||||||||
| FirstName: | ILSE | ||||||||
| MiddleName: | AIMEE | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 385 CALLE DE ALEGRA STE A | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755261105 | ||||||||
| FaxNumber: | 5755244266 | ||||||||
| Practice Location | |||||||||
| Address1: | 826 ANTHONY DR | ||||||||
| Address2: | |||||||||
| City: | ANTHONY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880219317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5752015135 | ||||||||
| FaxNumber: | 5754494052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2021 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | NM | N | Other Service Providers | Case Manager/Care Coordinator | 104100000X | X-12088 | NM | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 46039767 | 05 | NM | MEDICAID |