Provider Demographics
NPI:1255522074
Name:CARRILLO, MANUEL F (LCSW)
Entity type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:F
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9945
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-9998
Mailing Address - Country:US
Mailing Address - Phone:720-297-6150
Mailing Address - Fax:
Practice Address - Street 1:190 E 9TH AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-2736
Practice Address - Country:US
Practice Address - Phone:720-297-6150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
12362523OtherCAQH UNIVERSAL PROVIDER DATASOURCE