Provider Demographics
NPI:1407218977
Name:CASTILLA, ALISA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:CASTILLA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 MONTCLAIR WAY
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-7323
Mailing Address - Country:US
Mailing Address - Phone:770-988-7979
Mailing Address - Fax:478-202-7422
Practice Address - Street 1:1090 MONTCLAIR WAY
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-7323
Practice Address - Country:US
Practice Address - Phone:770-988-7979
Practice Address - Fax:478-202-7422
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009189235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist