Provider Demographics
NPI:1619268315
Name:CASTILLO, MALLARY
Entity Type:Individual
Prefix:
First Name:MALLARY
Middle Name:
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MALLARY
Other - Middle Name:
Other - Last Name:TOBEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1724 S HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-6826
Mailing Address - Country:US
Mailing Address - Phone:918-250-7093
Mailing Address - Fax:918-250-9976
Practice Address - Street 1:1724 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74112-6826
Practice Address - Country:US
Practice Address - Phone:918-250-7093
Practice Address - Fax:918-250-9976
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3739235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist