Healthcare Provider Details

I. General information

NPI: 1154247732
Provider Name (Legal Business Name): KATHLEEN CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 CAMINO DE LA SIESTA STE 220
SAN DIEGO CA
92108-3118
US

IV. Provider business mailing address

5030 CAMINO DE LA SIESTA STE 220
SAN DIEGO CA
92108-3118
US

V. Phone/Fax

Practice location:
  • Phone: 619-788-4660
  • Fax: 619-260-0201
Mailing address:
  • Phone: 619-788-4660
  • Fax: 619-260-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number53024
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: