Provider Demographics
NPI:1992379127
Name:CASTILLO, GERARDO ANTONIO
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:ANTONIO
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:OLIVEHURST
Mailing Address - State:CA
Mailing Address - Zip Code:95961-4759
Mailing Address - Country:US
Mailing Address - Phone:530-329-9732
Mailing Address - Fax:
Practice Address - Street 1:1942 BEVERLY AVE
Practice Address - Street 2:
Practice Address - City:OLIVEHURST
Practice Address - State:CA
Practice Address - Zip Code:95961-4759
Practice Address - Country:US
Practice Address - Phone:530-329-9732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health