Provider Demographics
NPI:1295403319
Name:CASTILLO, MACKENZIE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 BURROUGHS ST APT 205
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3390
Mailing Address - Country:US
Mailing Address - Phone:910-309-9024
Mailing Address - Fax:
Practice Address - Street 1:1500 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506
Practice Address - Country:US
Practice Address - Phone:304-293-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAT0017922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty