Healthcare Provider Details

I. General information

NPI: 1649754888
Provider Name (Legal Business Name): LIDIA CASTILLO HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 MCHENRY AVE
MODESTO CA
95350-4528
US

IV. Provider business mailing address

1539 MCHENRY AVE
MODESTO CA
95350-4528
US

V. Phone/Fax

Practice location:
  • Phone: 559-558-4051
  • Fax:
Mailing address:
  • Phone: 209-702-0139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number120802
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: