Provider Demographics
NPI:1275905655
Name:CASTRO, SELENE
Entity Type:Individual
Prefix:
First Name:SELENE
Middle Name:
Last Name:CASTRO
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 1:1029 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60064-1237
Mailing Address - Country:US
Mailing Address - Phone:847-208-8191
Mailing Address - Fax:
Practice Address - Street 1:31979 N FISH LAKE RD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073-9517
Practice Address - Country:US
Practice Address - Phone:847-546-6450
Practice Address - Fax:847-546-6760
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL29634101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)