Provider Demographics
NPI:1427672153
Name:CARRILLO, MARISSA (OTR/L)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24201 GINGERWOOD PL
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4508
Mailing Address - Country:US
Mailing Address - Phone:909-816-3925
Mailing Address - Fax:
Practice Address - Street 1:414 E SAN BERNARDINO RD
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1704
Practice Address - Country:US
Practice Address - Phone:626-594-6280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist