Provider Demographics
NPI:1497406359
Name:CARRILLO, CRAIG
Entity type:Individual
Prefix:
First Name:CRAIG
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 1:13936 MARLAND ST
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91746-2150
Mailing Address - Country:US
Mailing Address - Phone:626-363-5179
Mailing Address - Fax:
Practice Address - Street 1:8135 PAINTER AVE STE 201
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-3166
Practice Address - Country:US
Practice Address - Phone:562-698-6600
Practice Address - Fax:562-698-6613
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician