Provider Demographics
NPI:1407375439
Name:CARRASQUILLO, JOSE RAFAEL
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:RAFAEL
Last Name:CARRASQUILLO
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 1:2155 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-3301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2155 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-3301
Practice Address - Country:US
Practice Address - Phone:413-736-0395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA997303OtherNETWORK HEALTH
MA1134107113OtherBEACON
MA1134107113OtherMBHP
MA042622756OtherCCA
MA1134107113OtherNHP
MA12529OtherHNE
MAY10086OtherMEDICARE
MA1134107113OtherFALLON
MA1134107113Medicaid
MA71756OtherTUFTS