Healthcare Provider Details

I. General information

NPI: 1538024807
Provider Name (Legal Business Name): MR. ANTONIO CASILLAS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 LEHIGH AVE
MONTCLAIR CA
91763-3550
US

IV. Provider business mailing address

950 W D ST
ONTARIO CA
91762-3026
US

V. Phone/Fax

Practice location:
  • Phone: 909-624-5697
  • Fax: 909-445-1613
Mailing address:
  • Phone: 909-459-2500
  • Fax: 909-459-2542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: