Provider Demographics
NPI:1720567985
Name:CASTILLO, MIRA ECILA VILLAMARZO (PT, DPT, GCS)
Entity Type:Individual
Prefix:
First Name:MIRA ECILA
Middle Name:VILLAMARZO
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:PT, DPT, GCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 N SEMINARY ST APT 10
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2016
Mailing Address - Country:US
Mailing Address - Phone:309-569-6174
Mailing Address - Fax:
Practice Address - Street 1:280 E LOSEY ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2819
Practice Address - Country:US
Practice Address - Phone:309-343-2166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist