Healthcare Provider Details

I. General information

NPI: 1780381491
Provider Name (Legal Business Name): CARLOS DANIEL QUINTANILLA AVILES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROFESSIONAL CENTER PKWY
SAN RAFAEL CA
94903-2757
US

IV. Provider business mailing address

1019 TRENTON BLVD
SAN PABLO CA
94806-2895
US

V. Phone/Fax

Practice location:
  • Phone: 707-495-2938
  • Fax:
Mailing address:
  • Phone: 510-260-3794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164522
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: