Provider Demographics
NPI:1922457977
Name:CARRILLO, GUS (MSW)
Entity Type:Individual
Prefix:
First Name:GUS
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4036 RAYADO PL NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5538
Mailing Address - Country:US
Mailing Address - Phone:505-362-3378
Mailing Address - Fax:
Practice Address - Street 1:4036 RAYADO PL NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5538
Practice Address - Country:US
Practice Address - Phone:505-362-3378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-09587104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker