Healthcare Provider Details

I. General information

NPI: 1396281721
Provider Name (Legal Business Name): NICOLE RAQUEL CASTILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE R SCIORTINO

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2375 E CAMELBACK RD STE 600
PHOENIX AZ
85016-3493
US

IV. Provider business mailing address

2865 S 161ST DR
GOODYEAR AZ
85338-3598
US

V. Phone/Fax

Practice location:
  • Phone: 602-584-9860
  • Fax: 602-715-1135
Mailing address:
  • Phone: 575-640-0774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBEH-001100
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: