Provider Demographics
NPI:1700628955
Name:CARILLI, ETHAN (LMSW, CASAC-T)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:CARILLI
Suffix:
Gender:M
Credentials:LMSW, CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-2403
Mailing Address - Country:US
Mailing Address - Phone:516-659-0406
Mailing Address - Fax:
Practice Address - Street 1:1101 MAIN ST
Practice Address - Street 2:
Practice Address - City:PEEKSKILL
Practice Address - State:NY
Practice Address - Zip Code:10566-2907
Practice Address - Country:US
Practice Address - Phone:516-659-0406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NY124816104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)