Provider Demographics
NPI:1174252092
Name:CARRILLO, STEPHANIE (MSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3843 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4623
Mailing Address - Country:US
Mailing Address - Phone:773-884-2253
Mailing Address - Fax:
Practice Address - Street 1:3843 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4623
Practice Address - Country:US
Practice Address - Phone:773-884-2253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker