Provider Demographics
NPI:1740429661
Name:CARRILLO, LEANNE (PT)
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3663 E SUNSET RD
Mailing Address - Street 2:SUITE 503
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3218
Mailing Address - Country:US
Mailing Address - Phone:702-434-2800
Mailing Address - Fax:702-451-1034
Practice Address - Street 1:9975 S EASTERN AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183-7949
Practice Address - Country:US
Practice Address - Phone:702-434-2800
Practice Address - Fax:702-451-1034
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2182225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2182OtherSTATE OF NEVADA BOARD OF PHYSICAL THERAPY EXAMINERS