Healthcare Provider Details

I. General information

NPI: 1730540782
Provider Name (Legal Business Name): CANDELARIO JACK CASTILLO III LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 WILLOW PASS RD SUITE 200
CONCORD CA
94520-5823
US

IV. Provider business mailing address

1420 WILLOW PASS RD SUITE 200
CONCORD CA
94520-5823
US

V. Phone/Fax

Practice location:
  • Phone: 925-521-5159
  • Fax: 925-646-5622
Mailing address:
  • Phone: 925-521-5159
  • Fax: 925-646-5622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number79936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: