Provider Demographics
NPI:1639831951
Name:CASTRO-MORENO, JOHANNALY (PSYCH)
Entity Type:Individual
Prefix:
First Name:JOHANNALY
Middle Name:
Last Name:CASTRO-MORENO
Suffix:
Gender:F
Credentials:PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7603 WILDWOOD CT APT C1
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1873
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7603 WILDWOOD CT APT C1
Practice Address - Street 2:
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-1873
Practice Address - Country:US
Practice Address - Phone:571-639-9754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4597103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling