Provider Demographics
NPI:1477863561
Name:CASTILLO, SERGIO JR
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:CASTILLO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 E COOLEY DR
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3905
Mailing Address - Country:US
Mailing Address - Phone:909-580-3705
Mailing Address - Fax:
Practice Address - Street 1:1330 E COOLEY DR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3905
Practice Address - Country:US
Practice Address - Phone:909-580-3705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC01440115101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1477863561OtherMEDICAL
CA1477863561Medicaid