Provider Demographics
NPI:1083270813
Name:CASTILLO- REXACH, LUIS J
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:J
Last Name:CASTILLO- REXACH
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 1:20 N SAN PEDRO RD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-4188
Mailing Address - Country:US
Mailing Address - Phone:415-473-3438
Mailing Address - Fax:415-473-4216
Practice Address - Street 1:20 N SAN PEDRO RD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-4188
Practice Address - Country:US
Practice Address - Phone:415-473-3438
Practice Address - Fax:415-473-4216
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA144574106H00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANAOtherNEW CASE MANAGER