Provider Demographics
NPI:1952498388
Name:CARRILLO, RANDY LAWRENCE (MA MFT)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:LAWRENCE
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:MA MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5185 COMANCHE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941
Mailing Address - Country:US
Mailing Address - Phone:619-506-7412
Mailing Address - Fax:619-464-7772
Practice Address - Street 1:5185 COMANCHE DR
Practice Address - Street 2:SUITE B
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-3558
Practice Address - Country:US
Practice Address - Phone:619-506-7412
Practice Address - Fax:619-464-7772
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35837106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist