Healthcare Provider Details

I. General information

NPI: 1841875366
Provider Name (Legal Business Name): ANGIE BOTERO CASTRO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 N FRONTAGE RD
MANSFIELD CENTER CT
06250-1648
US

IV. Provider business mailing address

1007 N MAIN ST
DAYVILLE CT
06241-2170
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-2261
  • Fax: 860-450-1357
Mailing address:
  • Phone: 860-774-2020
  • Fax: 860-774-0826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5633
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13134
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: