Provider Demographics
NPI:1487794517
Name:CARRILLO, STEPHANIE COLLEEN (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:COLLEEN
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 NE LOOP 820
Mailing Address - Street 2:BUSINESS TOWER 1, STE 200
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-7209
Mailing Address - Country:US
Mailing Address - Phone:806-780-4180
Mailing Address - Fax:806-744-7458
Practice Address - Street 1:5225 S LOOP 289
Practice Address - Street 2:STE 210
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-1363
Practice Address - Country:US
Practice Address - Phone:806-780-4180
Practice Address - Fax:806-744-7458
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100284235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178080101Medicaid
TX8T3636OtherBLUECROSS BLUESHIELD
TX134759100OtherFIRSTCARE PROVIDER NUMBER