MEDICARE: DILLON PATRICK CARRASCO O'CONNELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	15671	CA

General Provider Information

NPI Number	:	1962075713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DILLON PATRICK CARRASCO O'CONNELL

Provider Business Mailing Address
First Line	:	1818 MOORE BLVD APT 112
Second Line	:
City	:	DAVIS
State	:	CA
Zip	:	95618-7636
Country	:	US
Telephone Number	:	619-964-0044
Fax Number	:

Provider Business Practice Location Address
First Line	:	1261 TRAVIS BLVD STE 200
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-4800
Country	:	US
Telephone Number	:	619-964-0044
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2021
Last Update Date	:	07/20/2021

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Directions to “ DILLON PATRICK CARRASCO O'CONNELL ” Practice Location

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