Provider Demographics
NPI:1225798697
Name:CARRILLO, JUAN RAMON (MED, MA)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:RAMON
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:MED, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:TX
Mailing Address - Zip Code:79830-4505
Mailing Address - Country:US
Mailing Address - Phone:432-386-7191
Mailing Address - Fax:
Practice Address - Street 1:405 N 8TH ST
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:TX
Practice Address - Zip Code:79830-4505
Practice Address - Country:US
Practice Address - Phone:432-386-7191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-27
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12121101YA0400X
TX78007101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional