Provider Demographics
NPI:1467171587
Name:CARILLO, COURTNEY MARIE (SUBSTANCE ABUSE ASSO)
Entity Type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:MARIE
Last Name:CARILLO
Suffix:
Gender:F
Credentials:SUBSTANCE ABUSE ASSO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 MEADOW HAWK LN
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88022-9727
Mailing Address - Country:US
Mailing Address - Phone:575-313-6714
Mailing Address - Fax:
Practice Address - Street 1:3200 32ND STREET BYP
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-7802
Practice Address - Country:US
Practice Address - Phone:575-597-2650
Practice Address - Fax:575-597-2651
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2022-0236101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)