Healthcare Provider Details

I. General information

NPI: 1891294450
Provider Name (Legal Business Name): JESSIE CASTILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 SUNSET DR STE 114
MIAMI FL
33173-3038
US

IV. Provider business mailing address

8215 SW 152ND AVE APT G-204
MIAMI FL
33193-4011
US

V. Phone/Fax

Practice location:
  • Phone: 305-508-5580
  • Fax:
Mailing address:
  • Phone: 786-554-1896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: