Provider Demographics
NPI:1780240119
Name:CARRILLO, CLARISSA SHADAE
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:SHADAE
Last Name:CARRILLO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95838-3466
Mailing Address - Country:US
Mailing Address - Phone:916-922-9868
Mailing Address - Fax:
Practice Address - Street 1:2829 WATT AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-6200
Practice Address - Country:US
Practice Address - Phone:916-531-0143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator