Provider Demographics
NPI:1134475197
Name:CARRILLO, LUKE IGNACIO (MHR, LPC)
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:IGNACIO
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:MHR, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 E THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-2600
Mailing Address - Country:US
Mailing Address - Phone:405-372-2202
Mailing Address - Fax:405-445-3780
Practice Address - Street 1:421 E THOMAS AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-2600
Practice Address - Country:US
Practice Address - Phone:405-372-2202
Practice Address - Fax:405-445-3780
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225C00000X
OK6651101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor