Healthcare Provider Details

I. General information

NPI: 1760090906
Provider Name (Legal Business Name): MARCOS ELVIRES CASTELLANO LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 OSUNA RD NE STE H4
ALBUQUERQUE NM
87107-5955
US

IV. Provider business mailing address

43 COUNTY ROAD 19
ESPANOLA NM
87532-9457
US

V. Phone/Fax

Practice location:
  • Phone: 505-345-2778
  • Fax:
Mailing address:
  • Phone: 505-929-4729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2023-1264
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: