Healthcare Provider Details

I. General information

NPI: 1245956960
Provider Name (Legal Business Name): JOSE CASTILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 10/14/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 ENTERPRISE WAY
MODESTO CA
95356
US

IV. Provider business mailing address

KAISER PERMANENTE BEHAVIORAL HEALTH DEPARTMENT 4700 ENTERPRISE WAY
MODESTO CA
95356
US

V. Phone/Fax

Practice location:
  • Phone: 209-550-6013
  • Fax:
Mailing address:
  • Phone: 185-526-8409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12428
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: