Provider Demographics
NPI:1124905302
Name:CARRILLO MORALES, JAIME ENRIQUE (RADT (R1625610725))
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:ENRIQUE
Last Name:CARRILLO MORALES
Suffix:
Gender:M
Credentials:RADT (R1625610725)
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:ENRIQUE
Other - Last Name:CARRILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:601 S HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-4521
Mailing Address - Country:US
Mailing Address - Phone:714-908-0028
Mailing Address - Fax:
Practice Address - Street 1:601 S HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-4521
Practice Address - Country:US
Practice Address - Phone:714-908-0028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-19
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1625610725101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)