=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639831951
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHANNALY CASTRO-MORENO PSYCH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2021
-----------------------------------------------------
Last Update Date | 10/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7603 WILDWOOD CT APT C1
-----------------------------------------------------
City | LORTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22079-1873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-639-9754
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7603 WILDWOOD CT APT C1
-----------------------------------------------------
City | LORTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22079-1873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 4597
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------