Healthcare Provider Details

I. General information

NPI: 1336173301
Provider Name (Legal Business Name): JT CARRILLO LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2132A CENTRAL AVE SE # 249
ALBUQUERQUE NM
87106-4083
US

IV. Provider business mailing address

2132A CENTRAL AVE SE # 249
ALBUQUERQUE NM
87106-4083
US

V. Phone/Fax

Practice location:
  • Phone: 505-259-7769
  • Fax:
Mailing address:
  • Phone: 505-259-7769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-04891
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: