Provider Demographics
NPI:1487816427
Name:CARRILLO, IVY MAE BUNACHITA (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:IVY MAE
Middle Name:BUNACHITA
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:IVY MAE
Other - Middle Name:BUNACHITA
Other - Last Name:RETARDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:3912 INDIAN GRASS LN
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078
Mailing Address - Country:US
Mailing Address - Phone:661-472-5413
Mailing Address - Fax:
Practice Address - Street 1:200 N NEW MEXICO DR.
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:TX
Practice Address - Zip Code:75009
Practice Address - Country:US
Practice Address - Phone:214-851-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7849225X00000X
TX122218225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist