Healthcare Provider Details

I. General information

NPI: 1932230612
Provider Name (Legal Business Name): ANA CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E FOOTHILL BLVD
RIALTO CA
92376
US

IV. Provider business mailing address

2712 W WINDHAVEN DR
RIALTO CA
92377-3451
US

V. Phone/Fax

Practice location:
  • Phone: 909-421-9451
  • Fax: 909-873-4494
Mailing address:
  • Phone: 626-967-1667
  • Fax: 626-967-6027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW72146
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: