=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629288758
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLE CARRILLO MSW, LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3216 NE 45TH PL STE 105
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98105-4028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-387-3614
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2030 WESTERN AVE APT 603
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98121-2124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-387-3614
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LW00008061
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------