Provider Demographics
NPI:1558717157
Name:JOAN ALICE CARRILLO, PH.D.
Entity Type:Organization
Organization Name:JOAN ALICE CARRILLO, PH.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:ALICE
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:305-666-7055
Mailing Address - Street 1:7901 SW 67TH AVE
Mailing Address - Street 2:201
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-4538
Mailing Address - Country:US
Mailing Address - Phone:305-666-7055
Mailing Address - Fax:786-349-0144
Practice Address - Street 1:7901 SW 67TH AVE
Practice Address - Street 2:201
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4538
Practice Address - Country:US
Practice Address - Phone:305-666-7055
Practice Address - Fax:786-349-0144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73918OtherMEDICARE PTAN