Provider Demographics
NPI:1003456757
Name:CASTILLO, GUILLERMO DE JESUS
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:DE JESUS
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 DUMONT AVE
Mailing Address - Street 2:
Mailing Address - City:DUMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:07628-3018
Mailing Address - Country:US
Mailing Address - Phone:718-679-2644
Mailing Address - Fax:
Practice Address - Street 1:501 CHESTNUT RIDGE RD STE 205
Practice Address - Street 2:
Practice Address - City:CHESTNUT RIDGE
Practice Address - State:NY
Practice Address - Zip Code:10977-5669
Practice Address - Country:US
Practice Address - Phone:845-638-3072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY033605235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program