Provider Demographics
NPI:1376169847
Name:CASTELLANOS ENRIQUE, ANGELICA M
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:M
Last Name:CASTELLANOS ENRIQUE
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 1:10420 SW 149TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-7764
Mailing Address - Country:US
Mailing Address - Phone:786-406-3573
Mailing Address - Fax:
Practice Address - Street 1:10420 SW 149TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-7764
Practice Address - Country:US
Practice Address - Phone:786-406-3573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-119440106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty