Provider Demographics
NPI:1053003194
Name:CARRILLO, MARIA GUADALUPE
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:GUADALUPE
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 1:4211 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-5699
Mailing Address - Country:US
Mailing Address - Phone:323-233-0425
Mailing Address - Fax:
Practice Address - Street 1:1200 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-5518
Practice Address - Country:US
Practice Address - Phone:323-233-0425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 373H00000X, 172V00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program