Healthcare Provider Details

I. General information

NPI: 1205170032
Provider Name (Legal Business Name): MALAYSHA GENEVA CASTILLO MFT INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2309 DALY ST
LOS ANGELES CA
90031
US

IV. Provider business mailing address

PO BOX 40323
PASADENA CA
91114-7323
US

V. Phone/Fax

Practice location:
  • Phone: 323-222-4591
  • Fax:
Mailing address:
  • Phone: 951-565-3658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number73058
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: