Provider Demographics
NPI:1750670402
Name:CARRILLO, RENE
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:
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 1:3751 STOCKER ST
Mailing Address - Street 2:
Mailing Address - City:VIEW PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90008-5101
Mailing Address - Country:US
Mailing Address - Phone:323-298-3618
Mailing Address - Fax:
Practice Address - Street 1:3751 STOCKER ST
Practice Address - Street 2:
Practice Address - City:VIEW PARK
Practice Address - State:CA
Practice Address - Zip Code:90008-5101
Practice Address - Country:US
Practice Address - Phone:323-298-3618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67694101YM0800X
CA1028051041C0700X
CA225400000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner