Provider Demographics
NPI:1750020442
Name:CASTRO, MARISA LISETTE (APC)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:LISETTE
Last Name:CASTRO
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 PIEDMONT RD NE STE 330
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1552
Mailing Address - Country:US
Mailing Address - Phone:404-351-2008
Mailing Address - Fax:
Practice Address - Street 1:3520 PIEDMONT RD NE STE 330
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-1552
Practice Address - Country:US
Practice Address - Phone:404-351-2008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC008514101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health