=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871911487
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE CASTILLO LCSW, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2014
-----------------------------------------------------
Last Update Date | 09/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1311 CHISHOLM TRL SUITE 301
-----------------------------------------------------
City | ROUND ROCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78681-2968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-426-1455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1311 CHISHOLM TRL SUITE 301
-----------------------------------------------------
City | ROUND ROCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78681-2968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-426-1455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | GRACE M CASTILLO
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 512-426-1455
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 25468
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------