Provider Demographics
NPI:1770885782
Name:CARRILLO, CRYSTAL M
Entity type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:M
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 1:550 S. VERMONT AVE
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-1630
Mailing Address - Country:US
Mailing Address - Phone:213-738-4775
Mailing Address - Fax:
Practice Address - Street 1:550 S. VERMONT AVE
Practice Address - Street 2:9TH FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1630
Practice Address - Country:US
Practice Address - Phone:213-738-4775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95393106H00000X
CA95920106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist