Healthcare Provider Details

I. General information

NPI: 1548486046
Provider Name (Legal Business Name): RUDY R CASTELLANO LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 E LINCOLN ST
LAS VEGAS NM
87701-4502
US

IV. Provider business mailing address

615 E LINCOLN ST
LAS VEGAS NM
87701-4502
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-8095
  • Fax: 505-426-8095
Mailing address:
  • Phone: 505-426-8095
  • Fax: 505-426-8095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1016
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: