Provider Demographics
NPI:1003770090
Name:CARRILLO RODRIGUEZ, RAUL
Entity type:Individual
Prefix:
First Name:RAUL
Middle Name:
Last Name:CARRILLO RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 BARNARD RD
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-4424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13911 N DALE MABRY HWY STE 108
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2414
Practice Address - Country:US
Practice Address - Phone:813-784-3619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-12
Last Update Date:2025-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-492558106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty