Provider Demographics
NPI:1225287568
Name:CARRILLO, RICARDO (PHD)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 ADAMS CT
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2336
Mailing Address - Country:US
Mailing Address - Phone:559-804-1671
Mailing Address - Fax:888-733-0664
Practice Address - Street 1:2576 SHATTUCK AVE STE 3
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2724
Practice Address - Country:US
Practice Address - Phone:559-804-1671
Practice Address - Fax:888-733-0664
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11696103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist