MEDICARE: REGINA CARRILLO,LLC

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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1386935096
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGINA CARRILLO,LLC

Provider Business Mailing Address
First Line	:	150 W SHADOWBEND AVE STE 200
Second Line	:
City	:	FRIENDSWOOD
State	:	TX
Zip	:	77546-3970
Country	:	US
Telephone Number	:	281-235-3010
Fax Number	:	832-383-3471

Provider Business Practice Location Address
First Line	:	150 W SHADOWBEND AVE STE 200
Second Line	:
City	:	FRIENDSWOOD
State	:	TX
Zip	:	77546-3970
Country	:	US
Telephone Number	:	281-235-3010
Fax Number	:	832-383-3471

Authorized Official
Title or Position	:	OWNER
Name	:	REGINA CARRILLO
Credential	:	LPC
Telephone Number	:	281-235-3010

Provider Enumeration Date	:	04/28/2011
Last Update Date	:	05/06/2014

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