Provider Demographics
NPI:1366940579
Name:CARRASCO, ADRIAN JACOB
Entity type:Individual
Prefix:
First Name:ADRIAN
Middle Name:JACOB
Last Name:CARRASCO
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 1:1076 SANTO ANTONIO DR STE B
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-8183
Mailing Address - Country:US
Mailing Address - Phone:909-433-9824
Mailing Address - Fax:909-433-9830
Practice Address - Street 1:1738 N WATERMAN AVE STE 1
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5131
Practice Address - Country:US
Practice Address - Phone:909-693-3302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2110806-I101YA0400X
101YA0400X, 175T00000X
CA171M00000X, 172V00000X, 373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist