Healthcare Provider Details

I. General information

NPI: 1750888665
Provider Name (Legal Business Name): OLIVER JOSE DE CASTRO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2018
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 W CARLTON PL
SANTA ANA CA
92704-4206
US

IV. Provider business mailing address

1055 E COLORADO BLVD STE 560
PASADENA CA
91106-2380
US

V. Phone/Fax

Practice location:
  • Phone: 646-645-6210
  • Fax:
Mailing address:
  • Phone: 818-241-6780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number147561
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: