Healthcare Provider Details

I. General information

NPI: 1104169408
Provider Name (Legal Business Name): KELLI CASTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 STANLEY AVE
CLARKSBURG WV
26301-3127
US

IV. Provider business mailing address

609 STANLEY AVE
CLARKSBURG WV
26301-3127
US

V. Phone/Fax

Practice location:
  • Phone: 727-501-4609
  • Fax:
Mailing address:
  • Phone: 727-501-4609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number10961
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: