Healthcare Provider Details

I. General information

NPI: 1033777107
Provider Name (Legal Business Name): OLIVIA CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 GRAND AVE
SACRAMENTO CA
95838-3466
US

IV. Provider business mailing address

811 GRAND AVE
SACRAMENTO CA
95838-3466
US

V. Phone/Fax

Practice location:
  • Phone: 916-942-9060
  • Fax: 916-942-9167
Mailing address:
  • Phone: 916-786-3750
  • Fax: 916-942-9060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW113778
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW113778
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number138910
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW113778
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: