Healthcare Provider Details

I. General information

NPI: 1700790532
Provider Name (Legal Business Name): PATRICIA CARRILLO
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12968 FREDERICK ST STE A
MORENO VALLEY CA
92553-5229
US

IV. Provider business mailing address

PO BOX 1273
SUN CITY CA
92585-0273
US

V. Phone/Fax

Practice location:
  • Phone: 951-208-0150
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW133382
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: