Healthcare Provider Details

I. General information

NPI: 1851563852
Provider Name (Legal Business Name): MARIA J CASTRONOVO MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S EAGLE ST
NEW BUFFALO MI
49117-1337
US

IV. Provider business mailing address

PO BOX 18
MICHIGAN CITY IN
46361
US

V. Phone/Fax

Practice location:
  • Phone: 219-877-4203
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number960010
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: