Provider Demographics
NPI:1700562204
Name:CARRILLOS, KENIA
Entity Type:Individual
Prefix:
First Name:KENIA
Middle Name:
Last Name:CARRILLOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KENIA
Other - Middle Name:YANORY
Other - Last Name:CARRILLOS ESCOBAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1510 GREENLAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-7072
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:888-403-6922
Practice Address - Street 1:1510 GREENLAWN BLVD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7072
Practice Address - Country:US
Practice Address - Phone:512-344-9216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22-221353106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician