Healthcare Provider Details

I. General information

NPI: 1871765917
Provider Name (Legal Business Name): MS. PATRICIA MARCELA CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 BROADWAY
RICHMOND CA
94804-1910
US

IV. Provider business mailing address

84 BROADWAY
RICHMOND CA
94804-1910
US

V. Phone/Fax

Practice location:
  • Phone: 510-231-7812
  • Fax: 510-231-7810
Mailing address:
  • Phone: 510-231-7812
  • Fax: 510-231-7810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number77779
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number123944
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: