Provider Demographics
NPI:1558809830
Name:CASTILLO GARCIA, FARA
Entity Type:Individual
Prefix:
First Name:FARA
Middle Name:
Last Name:CASTILLO GARCIA
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 1:1125 W 24TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-1951
Mailing Address - Country:US
Mailing Address - Phone:850-567-3590
Mailing Address - Fax:
Practice Address - Street 1:7351 SW 147TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-1118
Practice Address - Country:US
Practice Address - Phone:850-567-3590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT1864200106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020123600Medicaid