Provider Demographics
NPI:1669709465
Name:CASTANOS, GISSELLE MONIQUE (MACP)
Entity type:Individual
Prefix:
First Name:GISSELLE
Middle Name:MONIQUE
Last Name:CASTANOS
Suffix:
Gender:F
Credentials:MACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9258 SVL BOX
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5136
Mailing Address - Country:US
Mailing Address - Phone:760-220-2059
Mailing Address - Fax:
Practice Address - Street 1:2531 W WOODLAND DR
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2637
Practice Address - Country:US
Practice Address - Phone:714-226-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAIMF72676106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124100383Medicaid