Provider Demographics
NPI:1033656376
Name:CARRILLO, MYLDA (MED, LPC)
Entity Type:Individual
Prefix:MRS
First Name:MYLDA
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-1004
Mailing Address - Country:US
Mailing Address - Phone:602-200-0434
Mailing Address - Fax:602-200-0445
Practice Address - Street 1:11011 S 48TH ST STE 101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-1787
Practice Address - Country:US
Practice Address - Phone:480-331-3606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-11650101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional