Healthcare Provider Details

I. General information

NPI: 1356804991
Provider Name (Legal Business Name): BETHANY JORDAN CASTILLO LMHC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

973 CAMINO HERMOSA
CORRALES NM
87048-8436
US

IV. Provider business mailing address

2216 VIOLETA CIR SE
RIO RANCHO NM
87124-2585
US

V. Phone/Fax

Practice location:
  • Phone: 505-803-7459
  • Fax:
Mailing address:
  • Phone: 505-908-1237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1165835
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0203301
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: