Provider Demographics
NPI:1962016873
Name:CARVAJAL, ILEANA
Entity Type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:CARVAJAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12600 HILL COUNTRY BLVD STE R-100
Mailing Address - Street 2:
Mailing Address - City:BEE CAVE
Mailing Address - State:TX
Mailing Address - Zip Code:78738-6748
Mailing Address - Country:US
Mailing Address - Phone:512-565-3898
Mailing Address - Fax:
Practice Address - Street 1:835 PROTON RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4203
Practice Address - Country:US
Practice Address - Phone:512-772-5042
Practice Address - Fax:512-842-7446
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-21-51394103K00000X
TXRBT-19-105389106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician