Provider Demographics
NPI:1255095378
Name:MENDEZ CASTILLO, LISANNY
Entity type:Individual
Prefix:
First Name:LISANNY
Middle Name:
Last Name:MENDEZ 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 1:458 GRAND AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-3873
Mailing Address - Country:US
Mailing Address - Phone:860-462-6420
Mailing Address - Fax:
Practice Address - Street 1:458 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-3856
Practice Address - Country:US
Practice Address - Phone:860-462-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
CT171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist