MEDICARE: LISA CARRILLO PT

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	225100000X	Physical Therapist	1145811	TX

General Provider Information

NPI Number	:	1962422907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA CARRILLO PT

Provider Business Mailing Address
First Line	:	1881 BERING DR APT 37
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77057-3138
Country	:	US
Telephone Number	:	713-278-1531
Fax Number	:	713-278-1531

Provider Business Practice Location Address
First Line	:	1414 SOUTH LOOP W
Second Line	:	STE. #200
City	:	HOUSTON
State	:	TX
Zip	:	77054-3825
Country	:	US
Telephone Number	:	713-797-6106
Fax Number	:	713-490-1208

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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Directions to “ LISA CARRILLO PT” Practice Location

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