Provider Demographics
NPI:1023238102
Name:CARRILLO, EFRAIN DE LA CERDA (LCSW)
Entity type:Individual
Prefix:
First Name:EFRAIN
Middle Name:DE LA CERDA
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 N ROSEMONT
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 N ROSEMONT
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711
Practice Address - Country:US
Practice Address - Phone:520-481-3668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ110561041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ844341Medicaid