=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275727729
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOUISA CARRILLO GARCIA M.S.,CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2007
-----------------------------------------------------
Last Update Date | 08/28/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 808 TOWER DR. STE 7
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-335-8777
-----------------------------------------------------
Fax | 432-335-8787
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2424 SANTA CRUZ LN
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79763-2285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-335-0535
-----------------------------------------------------
Fax | 432-582-2303
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 100936
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------