Basic Information
| Provider Information | |||||||||
| NPI: | 1871131300 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRILLO | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2441 CABEZON BLVD SE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871241576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057171155 | ||||||||
| FaxNumber: | 5057171473 | ||||||||
| Practice Location | |||||||||
| Address1: | 2112 MAIN ST NE STE A | ||||||||
| Address2: | |||||||||
| City: | LOS LUNAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870317097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057171155 | ||||||||
| FaxNumber: | 5057171473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2019 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | M-11497 | NM | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | M-11497 | NM | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.