Provider Demographics
NPI:1942816673
Name:CARRILLO, CHRISTIAN JOSE ANTONIO
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:JOSE ANTONIO
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 1:2420 KLEIN RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-1801
Mailing Address - Country:US
Mailing Address - Phone:408-440-6115
Mailing Address - Fax:
Practice Address - Street 1:2420 KLEIN RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-1801
Practice Address - Country:US
Practice Address - Phone:408-440-6115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst