Healthcare Provider Details

I. General information

NPI: 1043829419
Provider Name (Legal Business Name): NISOM ANDREW REYES CASTILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3436 MARY ELDER RD NE
OLYMPIA WA
98506-5050
US

IV. Provider business mailing address

304 W BAY DR NW STE 101
OLYMPIA WA
98502-4956
US

V. Phone/Fax

Practice location:
  • Phone: 360-528-2590
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: