Provider Demographics
NPI:1871765917
Name:CARRILLO, PATRICIA MARCELA
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:MARCELA
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-1910
Mailing Address - Country:US
Mailing Address - Phone:510-231-7812
Mailing Address - Fax:510-231-7810
Practice Address - Street 1:84 BROADWAY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-1910
Practice Address - Country:US
Practice Address - Phone:510-231-7812
Practice Address - Fax:510-231-7810
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77779390200000X
CA123944106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program