Provider Demographics
NPI:1679189948
Name:CAROLLO MACHADO, JESUS
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:CAROLLO MACHADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6312 ROYAL HUNT DR APT 203
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-2533
Mailing Address - Country:US
Mailing Address - Phone:813-562-5104
Mailing Address - Fax:
Practice Address - Street 1:6312 ROYAL HUNT DR APT 203
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-2533
Practice Address - Country:US
Practice Address - Phone:813-562-5104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician