Provider Demographics
NPI:1932965100
Name:HERNANDEZ CARRILLO, KEYLA N/A
Entity Type:Individual
Prefix:
First Name:KEYLA
Middle Name:N/A
Last Name:HERNANDEZ CARRILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 E BLOOMINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8155
Mailing Address - Country:US
Mailing Address - Phone:813-655-8159
Mailing Address - Fax:
Practice Address - Street 1:8204 PENNYWELL PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-1625
Practice Address - Country:US
Practice Address - Phone:813-593-6710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-316263106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician