Healthcare Provider Details

I. General information

NPI: 1982985164
Provider Name (Legal Business Name): KEVIN BELCASTRO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 10/15/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5212 OGDEN ST UNIT A
SAN DIEGO CA
92105-3240
US

IV. Provider business mailing address

5212 OGDEN ST UNIT A
SAN DIEGO CA
92105-3240
US

V. Phone/Fax

Practice location:
  • Phone: 619-757-8722
  • Fax:
Mailing address:
  • Phone: 619-757-8722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number110463
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: