Provider Demographics
NPI:1093390221
Name:CARRILLO, ELIDA
Entity Type:Individual
Prefix:
First Name:ELIDA
Middle Name:
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 1:421 S DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-4464
Mailing Address - Country:US
Mailing Address - Phone:509-851-7622
Mailing Address - Fax:
Practice Address - Street 1:7401 W GRANDRIDGE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7831
Practice Address - Country:US
Practice Address - Phone:425-977-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician