Provider Demographics
NPI:1790292373
Name:CARRILLO, VANESSA JEAN (MSW, ASW)
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:JEAN
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:MSW, ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-2302
Mailing Address - Country:US
Mailing Address - Phone:442-265-1525
Mailing Address - Fax:
Practice Address - Street 1:202 N 8TH ST
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2302
Practice Address - Country:US
Practice Address - Phone:442-265-1525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW79072101Y00000X, 1041C0700X
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD4007906OtherDMV LICENSE