Provider Demographics
NPI:1174299986
Name:CARRILLO, MARIE CLAUDIA (PTA)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:CLAUDIA
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MILLBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94030-2926
Mailing Address - Country:US
Mailing Address - Phone:323-819-5223
Mailing Address - Fax:
Practice Address - Street 1:20211 PATIO DR STE 205
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4338
Practice Address - Country:US
Practice Address - Phone:510-537-3991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51399225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant