Provider Demographics
NPI:1467961268
Name:CARILLO-MEDINA, DIANA (RECOVERY ASSISTANT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:CARILLO-MEDINA
Suffix:
Gender:F
Credentials:RECOVERY ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 MILL RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-8511
Mailing Address - Country:US
Mailing Address - Phone:501-315-3105
Mailing Address - Fax:
Practice Address - Street 1:522 MILL RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-8511
Practice Address - Country:US
Practice Address - Phone:501-315-3105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator