Provider Demographics
NPI:1750173217
Name:CARRILLO, PRISCILLA DESIREE
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:DESIREE
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12502 W PERSHING ST
Mailing Address - Street 2:
Mailing Address - City:EL MIRAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85335-6392
Mailing Address - Country:US
Mailing Address - Phone:626-560-1329
Mailing Address - Fax:
Practice Address - Street 1:15116 N COTTON LN
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-9618
Practice Address - Country:US
Practice Address - Phone:623-322-8250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician