Basic Information
| Provider Information | |||||||||
| NPI: | 1346977238 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRILLO | ||||||||
| FirstName: | DIANNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1116 W VASSAR AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937054450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189679884 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3636 N FIRST ST | ||||||||
| Address2: | SUITE 112/124 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594762177 | ||||||||
| FaxNumber: | 8445636035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2022 | ||||||||
| LastUpdateDate: | 08/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 104492 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.