Provider Demographics
NPI:1578129060
Name:CARRILLO, CHRISTIAN (07786-C)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:07786-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 N BOULDER HWY # 89011
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89011-4120
Mailing Address - Country:US
Mailing Address - Phone:725-696-9673
Mailing Address - Fax:702-558-8700
Practice Address - Street 1:1536 N BOULDER HWY # 89011
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89011-4120
Practice Address - Country:US
Practice Address - Phone:725-696-9673
Practice Address - Fax:702-558-8700
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV07786-C101YA0400X
171M00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator