Provider Demographics
NPI:1689015117
Name:MURILLO, HELEN MAE
Entity Type:Individual
Prefix:
First Name:HELEN
Middle Name:MAE
Last Name:MURILLO
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 1:464 E B ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4108
Mailing Address - Country:US
Mailing Address - Phone:307-679-5577
Mailing Address - Fax:
Practice Address - Street 1:1101 CENTER ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-3383
Practice Address - Country:US
Practice Address - Phone:307-679-5577
Practice Address - Fax:307-460-7222
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WYBACB495015106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1871063974Medicaid