Healthcare Provider Details

I. General information

NPI: 1194494658
Provider Name (Legal Business Name): MAXIMILLIAN MYLES CASTORENO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35735 MOUND RD
STERLING HEIGHTS MI
48310-4728
US

IV. Provider business mailing address

26420 W WARREN ST
DEARBORN HEIGHTS MI
48127-1944
US

V. Phone/Fax

Practice location:
  • Phone: 586-510-7997
  • Fax:
Mailing address:
  • Phone: 313-676-7397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number459422
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: