Healthcare Provider Details

I. General information

NPI: 1467099671
Provider Name (Legal Business Name): BRIDGETTE KELLY CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44460 20TH ST W SIDE B
LANCASTER CA
93534-2714
US

IV. Provider business mailing address

44460 20TH ST W SIDE B
LANCASTER CA
93534-2714
US

V. Phone/Fax

Practice location:
  • Phone: 714-834-1111
  • Fax:
Mailing address:
  • Phone: 714-834-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: