Provider Demographics
NPI:1417292939
Name:CARRILLO, VANESSA (LMFT)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17935 CRABAPPLE CT
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407
Mailing Address - Country:US
Mailing Address - Phone:909-519-7249
Mailing Address - Fax:
Practice Address - Street 1:393 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91188-0001
Practice Address - Country:US
Practice Address - Phone:866-205-3595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 72066106H00000X
CA90485106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist