Provider Demographics
NPI:1013735356
Name:HENAO CASTRO, CARLOS EDUARDO (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:EDUARDO
Last Name:HENAO CASTRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1983 SE FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983
Mailing Address - Country:US
Mailing Address - Phone:772-254-2215
Mailing Address - Fax:
Practice Address - Street 1:1501 SW CASHMERE BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2026
Practice Address - Country:US
Practice Address - Phone:772-254-2215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1091283106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician