Healthcare Provider Details

I. General information

NPI: 1447410469
Provider Name (Legal Business Name): MARIO ALBERT CARRILLO BA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 W. HERNDON AVE
FRESNO CA
93711
US

IV. Provider business mailing address

1470 W. HERNDON AVE
FRESNO CA
93711
US

V. Phone/Fax

Practice location:
  • Phone: 559-256-2000
  • Fax: 559-256-3000
Mailing address:
  • Phone: 559-256-2000
  • Fax: 559-256-3000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: