Provider Demographics
NPI:1164197968
Name:CASTILLO HERNANDEZ, SANDY
Entity Type:Individual
Prefix:MR
First Name:SANDY
Middle Name:
Last Name:CASTILLO HERNANDEZ
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 1:7425 SW 152ND AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2358
Mailing Address - Country:US
Mailing Address - Phone:786-792-1552
Mailing Address - Fax:
Practice Address - Street 1:7425 SW 152ND AVE APT 201
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-2358
Practice Address - Country:US
Practice Address - Phone:786-792-1552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB942424106S00000X
FLMA91983225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist