Healthcare Provider Details

I. General information

NPI: 1639941081
Provider Name (Legal Business Name): STEPHANIE CASTRO LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2023
Last Update Date: 10/27/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 SW 10TH ST
RENTON WA
98057-5223
US

IV. Provider business mailing address

9508 56TH AVE SW APT EE206
LAKEWOOD WA
98499-7328
US

V. Phone/Fax

Practice location:
  • Phone: 206-461-4880
  • Fax:
Mailing address:
  • Phone: 760-214-6834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: