Provider Demographics
NPI:1396160859
Name:CARILLO, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CARILLO
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 1:755 S SIESTA AVE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91746-2706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 S SANTA ANITA AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-3536
Practice Address - Country:US
Practice Address - Phone:626-254-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-20
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner