MEDICARE: MRS. SARA ELLEN CARRILLO MSW, LICSW,MHP

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	104100000X	Social Worker	LW00009454	WA
2	1041C0700X	Clinical Social Worker	3971	OR
3	1041C0700X	Clinical Social Worker	LW00009454	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NONE	OTHER		MADIGAN ARMY MEDICAL CENTER
2	UNKNOWN	OTHER		UNKNOWN

General Provider Information

NPI Number	:	1942497789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SARA ELLEN CARRILLO MSW, LICSW,MHP

Provider Business Mailing Address
First Line	:	MADIGAN ARMY MEDICAL CENTER
Second Line	:	9040 JACKSON AVE
City	:	TACOMA
State	:	WA
Zip	:	98531-0001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	CHILD AND FAMILY BEHAVIORAL HEALTH SERVICES
Second Line	:	9040 JACKSON AVE
City	:	TACOMA
State	:	WA
Zip	:	98531-0001
Country	:	US
Telephone Number	:	253-968-4843
Fax Number	:

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

Provider Enumeration Date	:	09/25/2007
Last Update Date	:	02/22/2019

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