Basic Information
Provider Information
NPI: 1558687244
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CARRILLO
FirstName: BRENDA
MiddleName:  
NamePrefix: MISS
NameSuffix:  
Credential: M.A.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5555 RESERVOIR DR STE 204
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 921205137
CountryCode: US
TelephoneNumber: 8585732600
FaxNumber:  
Practice Location
Address1: 5555 RESERVOIR DR STE 204
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 92120
CountryCode: US
TelephoneNumber: 8585732600
FaxNumber:  
Other Information
ProviderEnumerationDate: 04/20/2010
LastUpdateDate: 05/29/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000X  N Behavioral Health & Social Service ProvidersCounselor 
103T00000X  N Behavioral Health & Social Service ProvidersPsychologist 
101YM0800X  Y Behavioral Health & Social Service ProvidersCounselorMental Health

ID Information
IDTypeStateIssuerDescription
155868724405CA MEDICAID


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