Provider Demographics
NPI:1598313207
Name:CASTILLO, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CASTILLO
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 1:7771 NW 159TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-6610
Mailing Address - Country:US
Mailing Address - Phone:305-761-5389
Mailing Address - Fax:
Practice Address - Street 1:7771 NW 159TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-6610
Practice Address - Country:US
Practice Address - Phone:305-761-5389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103105600Medicaid