Healthcare Provider Details

I. General information

NPI: 1063143931
Provider Name (Legal Business Name): EMILY MICHELLE CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 06/22/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1623 KINGS HWY
BROOKLYN NY
11229-1209
US

IV. Provider business mailing address

1623 KINGS HWY
BROOKLYN NY
11229-1209
US

V. Phone/Fax

Practice location:
  • Phone: 718-954-3800
  • Fax: 718-307-6871
Mailing address:
  • Phone: 718-954-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: