Provider Demographics
NPI:1497258362
Name:CARRILLO, CASSANDRA M (LCSW)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:M
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 S ATKINSON AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-7154
Mailing Address - Country:US
Mailing Address - Phone:575-578-4826
Mailing Address - Fax:
Practice Address - Street 1:1107 S ATKINSON AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-7154
Practice Address - Country:US
Practice Address - Phone:575-578-4826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-09035225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor