Provider Demographics
NPI:1720225584
Name:KELLY, HEIDI CASTRO (MA)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:CASTRO
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 E DAILY DR STE 310
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-6077
Mailing Address - Country:US
Mailing Address - Phone:805-231-6271
Mailing Address - Fax:
Practice Address - Street 1:751 E DAILY DR STE 320
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-0772
Practice Address - Country:US
Practice Address - Phone:805-231-6271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46480106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist