Provider Demographics
NPI:1699819730
Name:CASTRO-PENULLAR, SHASTA VICTORIA GRIMES (BSPT)
Entity Type:Individual
Prefix:MRS
First Name:SHASTA VICTORIA
Middle Name:GRIMES
Last Name:CASTRO-PENULLAR
Suffix:
Gender:F
Credentials:BSPT
Other - Prefix:MISS
Other - First Name:SHASTA VICTORIA
Other - Middle Name:GRIMES
Other - Last Name:CASTRO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:257 BOYD AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-1103
Mailing Address - Country:US
Mailing Address - Phone:201-200-0650
Mailing Address - Fax:
Practice Address - Street 1:242 10TH ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-1406
Practice Address - Country:US
Practice Address - Phone:201-795-2499
Practice Address - Fax:201-795-3579
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist