Provider Demographics
NPI:1225796568
Name:CASTILLO, KRYSTLE JADE
Entity Type:Individual
Prefix:
First Name:KRYSTLE
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 1:5616 BAUME WAY
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CA
Mailing Address - Zip Code:95368-9510
Mailing Address - Country:US
Mailing Address - Phone:209-798-9540
Mailing Address - Fax:
Practice Address - Street 1:5616 BAUME WAY
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CA
Practice Address - Zip Code:95368-9510
Practice Address - Country:US
Practice Address - Phone:209-798-9540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)