Provider Demographics
NPI:1275907909
Name:FAVELA-CASTRO, MARIA LUISA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LUISA
Last Name:FAVELA-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 1:1841 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-3234
Mailing Address - Country:US
Mailing Address - Phone:760-255-5700
Mailing Address - Fax:
Practice Address - Street 1:15095 AMARGOSA RD
Practice Address - Street 2:SUITE 201
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394
Practice Address - Country:US
Practice Address - Phone:760-245-4695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125291106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9983Medicaid