=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225798697
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN RAMON CARRILLO M.ED, M.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2021
-----------------------------------------------------
Last Update Date | 06/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 N 8TH ST
-----------------------------------------------------
City | ALPINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79830-4505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-386-7191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 405 N 8TH ST
-----------------------------------------------------
City | ALPINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79830-4505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-386-7191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 12121
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 78007
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 78007
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------