Provider Demographics
NPI:1629625322
Name:CARRILLO, ITZEL ZELENE
Entity Type:Individual
Prefix:
First Name:ITZEL
Middle Name:ZELENE
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128507 W KING TULL RD
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-8600
Mailing Address - Country:US
Mailing Address - Phone:509-303-0186
Mailing Address - Fax:
Practice Address - Street 1:3801 KERN WAY
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-6340
Practice Address - Country:US
Practice Address - Phone:509-574-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist