Provider Demographics
NPI:1578922274
Name:CARRILLO, JOSE A (CDP)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:A
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8514 W GAGE BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-8108
Mailing Address - Country:US
Mailing Address - Phone:509-440-3387
Mailing Address - Fax:509-491-3031
Practice Address - Street 1:8514 W GAGE BLVD STE G
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336
Practice Address - Country:US
Practice Address - Phone:509-440-3387
Practice Address - Fax:509-491-3031
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60417256101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)