Provider Demographics
NPI:1588965347
Name:CARRILLO, LISA MARIE (LMFT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6820 INDIANA AVE STE 240
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4262
Mailing Address - Country:US
Mailing Address - Phone:951-777-8176
Mailing Address - Fax:951-888-9049
Practice Address - Street 1:6820 INDIANA AVE STE 240
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4262
Practice Address - Country:US
Practice Address - Phone:951-777-8176
Practice Address - Fax:951-888-9049
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77468106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist