Provider Demographics
NPI:1891923231
Name:CARRILLO, AJA (SLP)
Entity Type:Individual
Prefix:
First Name:AJA
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:AJA
Other - Middle Name:A
Other - Last Name:WHATLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS SLP
Mailing Address - Street 1:310 A ST APT 1807
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-4314
Mailing Address - Country:US
Mailing Address - Phone:850-481-3114
Mailing Address - Fax:877-215-7951
Practice Address - Street 1:420 JAMES RIVER RD
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4867
Practice Address - Country:US
Practice Address - Phone:831-309-2101
Practice Address - Fax:877-215-7951
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32410235Z00000X
FLSA10343235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist