MEDICARE: TANYA CARRILLO RBT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		HI

General Provider Information

NPI Number	:	1386147601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANYA CARRILLO RBT

Provider Business Mailing Address
First Line	:	5198 IROQUOIS AVE
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-3252
Country	:	US
Telephone Number	:	619-947-9881
Fax Number	:

Provider Business Practice Location Address
First Line	:	5198 IROQUOIS AVE
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-3252
Country	:	US
Telephone Number	:	619-947-9881
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2018
Last Update Date	:	03/13/2018

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