Provider Demographics
NPI:1053528182
Name:CARRILLO, JUAN
Entity type:Individual
Prefix:
First Name:JUAN
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 1:1200 MAPLE ST STE 108
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-6330
Mailing Address - Country:US
Mailing Address - Phone:559-661-5194
Mailing Address - Fax:559-675-5149
Practice Address - Street 1:1200 MAPLE ST STE 108
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-6330
Practice Address - Country:US
Practice Address - Phone:559-661-5194
Practice Address - Fax:559-675-5149
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)