Provider Demographics
NPI:1730312083
Name:CARRILLO, MARCUS R
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:R
Last Name:CARRILLO
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 1:1330 SAN PEDRO DR NE
Mailing Address - Street 2:SUITE 201-B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-6744
Mailing Address - Country:US
Mailing Address - Phone:505-260-9912
Mailing Address - Fax:505-260-9934
Practice Address - Street 1:1330 SAN PEDRO DR NE
Practice Address - Street 2:SUITE 201-B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6744
Practice Address - Country:US
Practice Address - Phone:505-260-9912
Practice Address - Fax:505-260-9934
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor