Healthcare Provider Details

I. General information

NPI: 1518455245
Provider Name (Legal Business Name): CASTILLO PSYCHOLOGICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 S MAIN ST
LAS CRUCES NM
88005-3124
US

IV. Provider business mailing address

1605 S MAIN ST
LAS CRUCES NM
88005-3124
US

V. Phone/Fax

Practice location:
  • Phone: 575-527-0614
  • Fax: 575-541-4062
Mailing address:
  • Phone: 575-527-0614
  • Fax: 575-541-4062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1107
License Number StateNM

VIII. Authorized Official

Name: DR. JANETTE ELAINE CASTILLO
Title or Position: PSYCHOLOGIST
Credential: PH.D
Phone: 575-527-0614