Provider Demographics
NPI:1164932950
Name:CASTILLO, REYNA JADE
Entity Type:Individual
Prefix:MISS
First Name:REYNA
Middle Name:JADE
Last Name:CASTILLO
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 1:28 GLENELLEN RD # 2
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-5118
Mailing Address - Country:US
Mailing Address - Phone:575-779-3751
Mailing Address - Fax:
Practice Address - Street 1:75 AMORY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02119-1051
Practice Address - Country:US
Practice Address - Phone:857-399-1920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1093787095101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health