Provider Demographics
NPI:1407554181
Name:CASTRILLON CASALLAS, LEIDY
Entity Type:Individual
Prefix:
First Name:LEIDY
Middle Name:
Last Name:CASTRILLON CASALLAS
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 1:1110 THE POINTE DR # 1110
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-1920
Mailing Address - Country:US
Mailing Address - Phone:561-851-0261
Mailing Address - Fax:
Practice Address - Street 1:1110 THE POINTE DR # 1110
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-1920
Practice Address - Country:US
Practice Address - Phone:561-851-0261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-C236538036720106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician