=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033656376
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MYLDA CARRILLO M.ED, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2017
-----------------------------------------------------
Last Update Date | 04/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11011 S 48TH ST STE 101
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85044-1787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-331-3606
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2850 N 24TH ST
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85008-1004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-200-0434
-----------------------------------------------------
Fax | 602-200-0445
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC-11650
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------