Provider Demographics
NPI:1922155324
Name:CARRILLO, THOMAS L (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4091 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-6501
Mailing Address - Country:US
Mailing Address - Phone:909-591-3300
Mailing Address - Fax:562-943-3100
Practice Address - Street 1:4091 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-6501
Practice Address - Country:US
Practice Address - Phone:909-591-3300
Practice Address - Fax:562-943-3100
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17019103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical