Healthcare Provider Details

I. General information

NPI: 1467315069
Provider Name (Legal Business Name): HARRY A CARRILLO MED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1662 AVE PONCE DE LEON
SAN JUAN PR
00909-1834
US

IV. Provider business mailing address

1662 AVE PONCE DE LEON
SAN JUAN PR
00909-1834
US

V. Phone/Fax

Practice location:
  • Phone: 787-596-2555
  • Fax:
Mailing address:
  • Phone: 787-596-2555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1770
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: