Provider Demographics
NPI:1649713736
Name:DE CASTRO, MARIANNE GONZALES
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:GONZALES
Last Name:DE CASTRO
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 1:2490 SUN VALLEY CIR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-2230
Mailing Address - Country:US
Mailing Address - Phone:202-999-7944
Mailing Address - Fax:
Practice Address - Street 1:301 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2800
Practice Address - Country:US
Practice Address - Phone:301-216-4247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-22
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07548225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1447657507OtherNPI TYPE 2 (ORGANIZATION NPI)
MD4374045-00Medicaid
MD4374045-00Medicaid