Provider Demographics
NPI:1275985608
Name:CARRIL, TITO CHRISTHOFER
Entity Type:Individual
Prefix:
First Name:TITO
Middle Name:CHRISTHOFER
Last Name:CARRIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3146 TURRET DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-6065
Mailing Address - Country:US
Mailing Address - Phone:321-437-9705
Mailing Address - Fax:
Practice Address - Street 1:148 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5372
Practice Address - Country:US
Practice Address - Phone:321-437-9795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2019-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-17-37274106S00000X
FL1-19-36280103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018062600Medicaid