Provider Demographics
NPI:1891231809
Name:CASTRO, WILDA
Entity Type:Individual
Prefix:
First Name:WILDA
Middle Name:
Last Name:CASTRO
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 1:5600 E RUSSELL RD UNIT 2117
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-8014
Mailing Address - Country:US
Mailing Address - Phone:702-724-1677
Mailing Address - Fax:
Practice Address - Street 1:2501 N GREEN VALLEY PKWY
Practice Address - Street 2:BUILDING D SUITE 116 D
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-0273
Practice Address - Country:US
Practice Address - Phone:702-605-2766
Practice Address - Fax:702-938-9056
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI0779106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist