Provider Demographics
NPI:1508628694
Name:CASTILLO ROBERTSON, MONICA LIZETTE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:LIZETTE
Last Name:CASTILLO ROBERTSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2632 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-1152
Mailing Address - Country:US
Mailing Address - Phone:239-470-7663
Mailing Address - Fax:
Practice Address - Street 1:2632 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-1152
Practice Address - Country:US
Practice Address - Phone:239-470-7663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA20702235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist