Provider Demographics
NPI:1346945532
Name:CARRILLO, ANTHONY ZACHARIAH
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:ZACHARIAH
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 W FOOTHILL BLVD APT #H104
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-1406
Mailing Address - Country:US
Mailing Address - Phone:626-493-3358
Mailing Address - Fax:
Practice Address - Street 1:1406 W FOOTHILL BLVD APT #H104
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91784-1406
Practice Address - Country:US
Practice Address - Phone:626-493-3358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician