=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396557583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEETON KYLER CASTILLEJA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2025
-----------------------------------------------------
Last Update Date | 01/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 722 MORGAN BLVD # 116
-----------------------------------------------------
City | HARLINGEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78550-5139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-734-5044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 MIMOSA CIR
-----------------------------------------------------
City | SAN BENITO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78586-4112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-295-6244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------