Provider Demographics
NPI:1013686120
Name:CARRILLO LAZALDE, KARLA CECILIA
Entity Type:Individual
Prefix:
First Name:KARLA
Middle Name:CECILIA
Last Name:CARRILLO LAZALDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KC
Other - Middle Name:
Other - Last Name:CARRILLO LAZALDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5831 N 23RD ST APT 108
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-1094
Mailing Address - Country:US
Mailing Address - Phone:308-627-6727
Mailing Address - Fax:
Practice Address - Street 1:1299 FARNAM ST STE 300
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-1857
Practice Address - Country:US
Practice Address - Phone:402-235-1460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NERBT-21-179919103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst