Provider Demographics
NPI:1073954087
Name:CARRILLO, RUBI
Entity Type:Individual
Prefix:MISS
First Name:RUBI
Middle Name:
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 1:328 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5932
Mailing Address - Country:US
Mailing Address - Phone:209-663-2154
Mailing Address - Fax:
Practice Address - Street 1:1201 N EL DORADO ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1306
Practice Address - Country:US
Practice Address - Phone:209-468-3760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health