Provider Demographics
NPI:1396418208
Name:CASTANEDA VAZQUEZ, GRETCHEL DE LOS MILAGROS (CBHCM)
Entity type:Individual
Prefix:MRS
First Name:GRETCHEL
Middle Name:DE LOS MILAGROS
Last Name:CASTANEDA VAZQUEZ
Suffix:
Gender:F
Credentials:CBHCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3013 NW DOUGLAS CIR
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-8657
Mailing Address - Country:US
Mailing Address - Phone:786-236-0812
Mailing Address - Fax:
Practice Address - Street 1:3013 NW DOUGLAS CIR
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33993-8657
Practice Address - Country:US
Practice Address - Phone:786-236-8012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCM103939104100000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL122859100Medicaid