=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639331580
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GUSTAVO MIGUEL CASTRO MD COUNSELOR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2008
-----------------------------------------------------
Last Update Date | 07/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3263 N FRONT STREET
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-426-1077
-----------------------------------------------------
Fax | 215-429-1086
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 S 13TH ST APT. 1 C
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-5615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-455-3768
-----------------------------------------------------
Fax | 215-426-1086
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------