Provider Demographics
NPI:1942497789
Name:CARRILLO, SARA ELLEN (MSW, LICSW,MHP)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:ELLEN
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:MSW, LICSW,MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MADIGAN ARMY MEDICAL CENTER
Mailing Address - Street 2:9040 JACKSON AVE
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CHILD AND FAMILY BEHAVIORAL HEALTH SERVICES
Practice Address - Street 2:9040 JACKSON AVE
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98531-0001
Practice Address - Country:US
Practice Address - Phone:253-968-4843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00009454104100000X, 1041C0700X
OR39711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherMADIGAN ARMY MEDICAL CENTER
UNKNOWNOtherUNKNOWN