Provider Demographics
NPI:1346977238
Name:CARRILLO, DIANNA
Entity Type:Individual
Prefix:
First Name:DIANNA
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 1:1116 W VASSAR AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-4450
Mailing Address - Country:US
Mailing Address - Phone:818-967-9884
Mailing Address - Fax:
Practice Address - Street 1:3636 N FIRST ST
Practice Address - Street 2:SUITE 112/124
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726
Practice Address - Country:US
Practice Address - Phone:559-476-2177
Practice Address - Fax:844-563-6035
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104492101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health