Provider Demographics
NPI:1679279624
Name:CASTRO, REBECCA ALEXANDRA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ALEXANDRA
Last Name:CASTRO
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 1:12021 WILMINGTON AVE BLDG 18
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-3019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12021 WILMINGTON AVE BLDG 18
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3019
Practice Address - Country:US
Practice Address - Phone:424-454-6081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator