MEDICARE: LISA MARIE CARRILLO LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	77468	CA

General Provider Information

NPI Number	:	1588965347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARIE CARRILLO LMFT

Provider Business Mailing Address
First Line	:	6820 INDIANA AVE STE 240
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-4262
Country	:	US
Telephone Number	:	951-777-8176
Fax Number	:	951-888-9049

Provider Business Practice Location Address
First Line	:	6820 INDIANA AVE STE 240
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-4262
Country	:	US
Telephone Number	:	951-777-8176
Fax Number	:	951-888-9049

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2010
Last Update Date	:	11/30/2016

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