Healthcare Provider Details

I. General information

NPI: 1194640193
Provider Name (Legal Business Name): YESSIKA PAOLA CASTEDO BLANCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5290 SHAWNEE RD STE 220
ALEXANDRIA VA
22312-2377
US

IV. Provider business mailing address

707 TENNESSEE AVE
ALEXANDRIA VA
22305-1157
US

V. Phone/Fax

Practice location:
  • Phone: 703-539-8616
  • Fax:
Mailing address:
  • Phone: 703-539-8616
  • Fax: 703-370-3409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-2838031
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: