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General NPI Number Information
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NPI Number | 1639700685
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Entity Type | Individual
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Provider Name | MYRA CLEMENTINE CASTANEDA LMFT
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Gender | Female
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Dates
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Enumeration Date | 01/29/2020
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Last Update Date | 01/29/2020
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Provider Practice Location Address
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Address Line | 5100 N RAVENSWOOD AVE STE 209
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City | CHICAGO
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State | IL
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Zip | 60640-1710
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Country | US
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Telephone | 773-769-7204
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Fax |
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Provider Business Mailing Address
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Address Line | 5011 N CALIFORNIA AVE APT 2
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City | CHICAGO
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State | IL
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Zip | 60625-3617
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Country | US
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Telephone | 773-656-2504
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 166.001321
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License Number State | IL
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