Healthcare Provider Details

I. General information

NPI: 1891042115
Provider Name (Legal Business Name): ALLYSSAN CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2012
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 MONTANA AVE SUITE G
EL PASO TX
79925-2155
US

IV. Provider business mailing address

5316 TRAI LLAKE DRIVE
FORT WORTH TX
76133
US

V. Phone/Fax

Practice location:
  • Phone: 915-838-7604
  • Fax: 817-789-6849
Mailing address:
  • Phone: 817-292-8787
  • Fax: 817-789-6849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number35460
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: