Healthcare Provider Details

I. General information

NPI: 1487096400
Provider Name (Legal Business Name): ROSEALINDA DANIELLE CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2013
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10652 BURTON ST APT A
RIVERSIDE CA
92505-1637
US

IV. Provider business mailing address

PO BOX 2215
SAN BERNARDINO CA
92406-2215
US

V. Phone/Fax

Practice location:
  • Phone: 909-496-6407
  • Fax:
Mailing address:
  • Phone: 909-496-6407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number103075
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: