Provider Demographics
NPI:1669134755
Name:CASTRO, AMANDA CELESTE (R1444050921)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:CELESTE
Last Name:CASTRO
Suffix:
Gender:F
Credentials:R1444050921
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9207 BEACH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90002-2426
Mailing Address - Country:US
Mailing Address - Phone:213-458-0118
Mailing Address - Fax:
Practice Address - Street 1:2504 W MANCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90305-2520
Practice Address - Country:US
Practice Address - Phone:323-751-3804
Practice Address - Fax:323-750-5885
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1444050921101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)