Provider Demographics
NPI:1760959563
Name:CASTREJON, SHANEL
Entity Type:Individual
Prefix:
First Name:SHANEL
Middle Name:
Last Name:CASTREJON
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 1:22978 EL TORO RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4961
Mailing Address - Country:US
Mailing Address - Phone:510-317-1444
Mailing Address - Fax:
Practice Address - Street 1:22978 EL TORO RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4961
Practice Address - Country:US
Practice Address - Phone:510-317-1444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA121060106H00000X
174400000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No174400000XOther Service ProvidersSpecialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program