MEDICARE: SUSAN CARRILLO M.A., LPA

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	103T00000X	Psychologist	2268	NC

General Provider Information

NPI Number	:	1487096822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN CARRILLO M.A., LPA

Provider Business Mailing Address
First Line	:	205 PLAZA DR
Second Line	:	SUITE C
City	:	GREENVILLE
State	:	NC
Zip	:	27858-6752
Country	:	US
Telephone Number	:	252-756-1316
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 PLAZA DR
Second Line	:	SUITE C
City	:	GREENVILLE
State	:	NC
Zip	:	27858-6752
Country	:	US
Telephone Number	:	252-756-1316
Fax Number	:

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

Provider Enumeration Date	:	07/26/2013
Last Update Date	:	07/26/2013

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