Healthcare Provider Details

I. General information

NPI: 1134475197
Provider Name (Legal Business Name): LUKE IGNACIO CARRILLO MHR, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 E THOMAS AVE
STILLWATER OK
74075-2600
US

IV. Provider business mailing address

421 E THOMAS AVE
STILLWATER OK
74075-2600
US

V. Phone/Fax

Practice location:
  • Phone: 405-372-2202
  • Fax: 405-445-3780
Mailing address:
  • Phone: 405-372-2202
  • Fax: 405-445-3780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6651
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: