Provider Demographics
NPI:1770502858
Name:CARRILLO, JOAN ALICE (PHD)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:ALICE
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NE 15TH ST
Mailing Address - Street 2:#208
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030
Mailing Address - Country:US
Mailing Address - Phone:305-666-7055
Mailing Address - Fax:305-245-3901
Practice Address - Street 1:100 NE 15TH ST
Practice Address - Street 2:#208
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030
Practice Address - Country:US
Practice Address - Phone:305-666-7055
Practice Address - Fax:305-245-3901
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4463103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
73918OtherBCBS
73918Medicare ID - Type Unspecified