Healthcare Provider Details

I. General information

NPI: 1134604689
Provider Name (Legal Business Name): MISS ANN MARY CASTRO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2018
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13223 BLACK MOUNTAIN RD # 1508
SAN DIEGO CA
92129-2698
US

IV. Provider business mailing address

13223 BLACK MOUNTAIN RD # 1508
SAN DIEGO CA
92129-2698
US

V. Phone/Fax

Practice location:
  • Phone: 858-753-5082
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number38616
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: