MEDICARE: JORDAN CASTRO LMSW, CASAC-2

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	30762	NY
2	1041S0200X	School Social Worker	112056	NY
3	104100000X	Social Worker	112056	NY

General Provider Information

NPI Number	:	1225617772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN CASTRO LMSW, CASAC-2

Provider Business Mailing Address
First Line	:	3034 GOMER ST
Second Line	:
City	:	YORKTOWN HEIGHTS
State	:	NY
Zip	:	10598-2724
Country	:	US
Telephone Number	:	917-715-2841
Fax Number	:

Provider Business Practice Location Address
First Line	:	3034 GOMER ST
Second Line	:
City	:	YORKTOWN HEIGHTS
State	:	NY
Zip	:	10598-2724
Country	:	US
Telephone Number	:	917-715-2841
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2021
Last Update Date	:	10/05/2023

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