Basic Information
| Provider Information | |||||||||
| NPI: | 1144810557 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRILLO | ||||||||
| FirstName: | MELINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 TWILIGHT ST | ||||||||
| Address2: | |||||||||
| City: | PLACENTIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928704842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148736587 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1207 E FRUIT ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149539373 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2021 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YA0400X | R1419750221 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.