Provider Demographics
NPI:1346830338
Name:CARRILLO ROSAS, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:CARRILLO ROSAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 TAVERN ROAD
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-2619
Mailing Address - Country:US
Mailing Address - Phone:760-924-1740
Mailing Address - Fax:
Practice Address - Street 1:1290 TAVERN ROAD
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546-2619
Practice Address - Country:US
Practice Address - Phone:769-924-1740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician