Provider Demographics
NPI:1124713649
Name:ONEILL, CARRYN TAYLOR
Entity type:Individual
Prefix:
First Name:CARRYN
Middle Name:TAYLOR
Last Name:ONEILL
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 1:4451 30TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-4232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4451 30TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-4232
Practice Address - Country:US
Practice Address - Phone:619-914-2391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17747101YP2500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program