MEDICARE: IANA MARI CARRILLO

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1982593513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IANA MARI CARRILLO

Provider Business Mailing Address
First Line	:	1075 CREEKSIDE RIDGE DR STE 280
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95678-3504
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	194 WALKER VALLEY RD
Second Line	:
City	:	CASTROVILLE
State	:	CA
Zip	:	95012-9709
Country	:	US
Telephone Number	:	831-809-6944
Fax Number	:

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

Provider Enumeration Date	:	06/30/2025
Last Update Date	:	06/30/2025

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Directions to “ IANA MARI CARRILLO ” Practice Location

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