Healthcare Provider Details

I. General information

NPI: 1972143592
Provider Name (Legal Business Name): MARIANA S CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2020
Last Update Date: 01/11/2020
Certification Date: 01/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S KNOTT AVE APT 3
ANAHEIM CA
92804-1478
US

IV. Provider business mailing address

201 S KNOTT AVE APT 3
ANAHEIM CA
92804-1478
US

V. Phone/Fax

Practice location:
  • Phone: 714-829-6919
  • Fax:
Mailing address:
  • Phone: 714-829-6919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number41292
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: