Healthcare Provider Details

I. General information

NPI: 1790289080
Provider Name (Legal Business Name): MARICRUZ PAT CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 ALTA RD STE 6100
SAN DIEGO CA
92158-0001
US

IV. Provider business mailing address

734 10TH AVE
SAN DIEGO CA
92101-6502
US

V. Phone/Fax

Practice location:
  • Phone: 619-671-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSB94026737
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: