Provider Demographics
NPI:1639700685
Name:CASTANEDA, MYRA CLEMENTINE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:CLEMENTINE
Last Name:CASTANEDA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5011 N CALIFORNIA AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3617
Mailing Address - Country:US
Mailing Address - Phone:773-656-2504
Mailing Address - Fax:
Practice Address - Street 1:5100 N RAVENSWOOD AVE STE 209
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1710
Practice Address - Country:US
Practice Address - Phone:773-769-7204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.001321106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty