Basic Information
| Provider Information | |||||||||
| NPI: | 1356972251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRADILLA | ||||||||
| FirstName: | CAROLINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5580 MORENO ST SPC 49 | ||||||||
| Address2: | |||||||||
| City: | MONTCLAIR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917631601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092619113 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14677 MERRILL AVE | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923354219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516432340 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2020 | ||||||||
| LastUpdateDate: | 01/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW93108 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.