Provider Demographics
NPI:1346533759
Name:CARRILLO, KATHLEEN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:876 YORKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:KY
Mailing Address - Zip Code:41001-8276
Mailing Address - Country:US
Mailing Address - Phone:812-622-0448
Mailing Address - Fax:
Practice Address - Street 1:876 YORKSHIRE DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:KY
Practice Address - Zip Code:41001-8276
Practice Address - Country:US
Practice Address - Phone:812-622-0448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY11-030235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist