Basic Information
| Provider Information | |||||||||
| NPI: | 1508131970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRILLO | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | MANUEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7524 SERAPIS AVE | ||||||||
| Address2: | |||||||||
| City: | PICO RIVERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906604142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624779500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11015 BLOOMFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA FE SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906704601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629062676 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2012 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 96965 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.