Provider Demographics
NPI:1649754888
Name:CASTILLO HERNANDEZ, LIDIA
Entity Type:Individual
Prefix:
First Name:LIDIA
Middle Name:
Last Name:CASTILLO HERNANDEZ
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 1:1539 MCHENRY AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4528
Mailing Address - Country:US
Mailing Address - Phone:209-702-0139
Mailing Address - Fax:
Practice Address - Street 1:1539 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4528
Practice Address - Country:US
Practice Address - Phone:559-558-4051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120802101YP2500X
106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional