Provider Demographics
NPI:1245614999
Name:CARRILLO, CLAUDIA (MH15788)
Entity Type:Individual
Prefix:
First Name:CLAUDIA
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:MH15788
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4729 US 98 S STE 104
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-4323
Mailing Address - Country:US
Mailing Address - Phone:863-877-1855
Mailing Address - Fax:863-646-6111
Practice Address - Street 1:4729 US 98 S STE 104
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812
Practice Address - Country:US
Practice Address - Phone:863-877-1855
Practice Address - Fax:863-646-6111
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH15788101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health