Healthcare Provider Details

I. General information

NPI: 1770502858
Provider Name (Legal Business Name): JOAN ALICE CARRILLO PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 12/07/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NE 15TH ST #208
HOMESTEAD FL
33030
US

IV. Provider business mailing address

100 NE 15TH ST #208
HOMESTEAD FL
33030
US

V. Phone/Fax

Practice location:
  • Phone: 305-666-7055
  • Fax: 305-245-3901
Mailing address:
  • Phone: 305-666-7055
  • Fax: 305-245-3901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY4463
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: