Healthcare Provider Details

I. General information

NPI: 1134826126
Provider Name (Legal Business Name): HECTOR RUBEN CARRILLO LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2023
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 CARLISLE BLVD NE
ALBUQUERQUE NM
87110-4905
US

IV. Provider business mailing address

407 QUINCY ST NE
ALBUQUERQUE NM
87108-1346
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-9911
  • Fax:
Mailing address:
  • Phone: 505-506-2077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2023-0122
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: