Provider Demographics
NPI:1568019347
Name:CARRILLO, DESTINY ARISSA
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:ARISSA
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 1:824 N E ST
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-2724
Mailing Address - Country:US
Mailing Address - Phone:559-804-3468
Mailing Address - Fax:
Practice Address - Street 1:160 N L ST
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-4114
Practice Address - Country:US
Practice Address - Phone:559-837-1223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY4529626103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst