Provider Demographics
NPI:1750327649
Name:CARRILLO, JAVIER (PHD)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 VISCOUNT BLVD STE AN117
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-5897
Mailing Address - Country:US
Mailing Address - Phone:915-491-0707
Mailing Address - Fax:
Practice Address - Street 1:3115 SOUTH LOOP 306
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-5983
Practice Address - Country:US
Practice Address - Phone:325-942-1952
Practice Address - Fax:325-942-1517
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24690103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117826108Medicaid
TX87709AOtherBCBS
TX8F7033Medicare UPIN
TX117826106Medicaid