Provider Demographics
NPI:1740399666
Name:CASTRONOVO, NEIL RYAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:NEIL
Middle Name:RYAN
Last Name:CASTRONOVO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 MARWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-1716
Mailing Address - Country:US
Mailing Address - Phone:508-754-0393
Mailing Address - Fax:
Practice Address - Street 1:19 MARWOOD RD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01602-1716
Practice Address - Country:US
Practice Address - Phone:508-754-0393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPSYCHOLOGIST 3144103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0516023Medicaid
MACAWO325468Medicare ID - Type Unspecified