Basic Information
| Provider Information | |||||||||
| NPI: | 1760758866 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRILLO | ||||||||
| FirstName: | SOCORRO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3883 ALBILLO LOOP | ||||||||
| Address2: | |||||||||
| City: | PERRIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925717526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519404733 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13800 HEACOCK ST | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925533339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516530819 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2012 | ||||||||
| LastUpdateDate: | 03/22/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.