Provider Demographics
NPI:1265686554
Name:CASTILLO, AUDRA ELIZABETH (LMT)
Entity Type:Individual
Prefix:MRS
First Name:AUDRA
Middle Name:ELIZABETH
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2033 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6371
Mailing Address - Country:US
Mailing Address - Phone:541-890-4596
Mailing Address - Fax:541-227-6705
Practice Address - Street 1:1117 E MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7404
Practice Address - Country:US
Practice Address - Phone:541-779-2577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11588225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist