Provider Demographics
NPI:1528575636
Name:CASILLAS, ANTONIO (MA)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:CASILLAS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2579 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-1159
Mailing Address - Country:US
Mailing Address - Phone:510-446-7100
Mailing Address - Fax:
Practice Address - Street 1:2579 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1159
Practice Address - Country:US
Practice Address - Phone:510-446-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC6119101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAPCC6119OtherASSOCIATE PROFESSIONAL CLINICAL COUNSELOR