Healthcare Provider Details

I. General information

NPI: 1174299986
Provider Name (Legal Business Name): MARIE CLAUDIA CARRILLO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20211 PATIO DR STE 205
CASTRO VALLEY CA
94546-4338
US

IV. Provider business mailing address

1244 LAKE ST
MILLBRAE CA
94030-2926
US

V. Phone/Fax

Practice location:
  • Phone: 510-537-3991
  • Fax:
Mailing address:
  • Phone: 323-819-5223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number51399
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: