Provider Demographics
NPI:1679961825
Name:CARRILLO, DANIEL (INTERN)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 S STATE ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-4922
Mailing Address - Country:US
Mailing Address - Phone:951-791-3350
Mailing Address - Fax:951-791-3353
Practice Address - Street 1:1370 S STATE ST STE A
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4922
Practice Address - Country:US
Practice Address - Phone:951-791-3350
Practice Address - Fax:951-791-3353
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAC041400417101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA333903Medicaid
CA333901Medicaid