Provider Demographics
NPI:1508131970
Name:CARRILLO, DAVID MANUEL
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MANUEL
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 1:7524 SERAPIS AVE
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-4142
Mailing Address - Country:US
Mailing Address - Phone:562-477-9500
Mailing Address - Fax:
Practice Address - Street 1:11015 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-4601
Practice Address - Country:US
Practice Address - Phone:562-906-2676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-18
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA969651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical