| Doctor Name: | MRS. NICOLE CARRILLO |
| NPI Number: | 1366863995 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | CCC |
| License Number: | 2013013585 |
| Business Practice Address: | 640 Nw Jefferson St Grain Valley, MO - 640298278 |
| Business Phone Number: | 8167852284 |
| Business Fax Number: | 8166334371 |
| Mailing Address: | 701 Opera House Ln, ODESSA |
| State: | MO |
| Postal Code: | 640761624 |
| Phone Number: | 8167852284 |
| Fax Number: | 8166334371 |
| NPI Enumeration Date: | 12/28/2013 |
| NPI Last Update Date: | 12/28/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | 2013013585 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MO |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |