Provider Demographics
NPI:1750039772
Name:MORA CASTILLO, MARISOL
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:MORA CASTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12502 TRAIL BLAZER LOOP APT 202
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-2510
Mailing Address - Country:US
Mailing Address - Phone:786-667-9575
Mailing Address - Fax:
Practice Address - Street 1:12502 TRAIL BLAZER LOOP APT 202
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-2510
Practice Address - Country:US
Practice Address - Phone:786-667-9575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician