Provider Demographics
NPI:1104397165
Name:CASTANEDA, DESIREE RENE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:RENE
Last Name:CASTANEDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2437 GRAND AVE STE BCD
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-6620
Mailing Address - Country:US
Mailing Address - Phone:805-941-3656
Mailing Address - Fax:
Practice Address - Street 1:2437 GRAND AVE STE BCD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6620
Practice Address - Country:US
Practice Address - Phone:805-941-3656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF4361160106E00000X, 103K00000X
CAF431160106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician