Provider Demographics
NPI:1326608670
Name:CASTRO, NICOLE R
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
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 1:2 WESTERVELT AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07506-3817
Mailing Address - Country:US
Mailing Address - Phone:862-888-6281
Mailing Address - Fax:
Practice Address - Street 1:1001 W MIDDLESEX AVE
Practice Address - Street 2:
Practice Address - City:PORT READING
Practice Address - State:NJ
Practice Address - Zip Code:07064-1518
Practice Address - Country:US
Practice Address - Phone:862-888-6281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002492002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer