Basic Information
| Provider Information | |||||||||
| NPI: | 1073902706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRILLO | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | JUSTINE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 SAN FELIPE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951351503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082381552 | ||||||||
| FaxNumber: | 4082381552 | ||||||||
| Practice Location | |||||||||
| Address1: | 4205 SAN FELIPE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951351503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082381552 | ||||||||
| FaxNumber: | 4082381552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2015 | ||||||||
| LastUpdateDate: | 04/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 42031 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.