Provider Demographics
NPI:1720506082
Name:BELTRAN CARRILLO, ERNESTO
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:BELTRAN 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 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 W BROADWAY STE 800
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3546
Practice Address - Country:US
Practice Address - Phone:760-562-7199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBA-TL-0022103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst