Healthcare Provider Details

I. General information

NPI: 1760774673
Provider Name (Legal Business Name): BRANDY LEE CASTILLO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 09/15/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 EAST RIVER ROAD
BELEN NM
87002
US

IV. Provider business mailing address

27 CRUCES LOOP
LOS LUNAS NM
87031-0015
US

V. Phone/Fax

Practice location:
  • Phone: 505-312-0040
  • Fax: 505-213-0066
Mailing address:
  • Phone: 505-967-9975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-07362
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: