Provider Demographics
NPI:1356492193
Name:CARRILLO, DIANE E (PT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:E
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7759 N SILVERBELL RD APT 10105
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85743-8294
Mailing Address - Country:US
Mailing Address - Phone:520-403-6192
Mailing Address - Fax:
Practice Address - Street 1:7759 N SILVERBELL RD APT 10105
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85743
Practice Address - Country:US
Practice Address - Phone:520-403-6192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33333225100000X
LPT-30580225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist