Provider Demographics
NPI:1831831858
Name:ROSA CASTRO, KEVEN OMAR
Entity type:Individual
Prefix:
First Name:KEVEN
Middle Name:OMAR
Last Name:ROSA CASTRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15115 LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-3702
Mailing Address - Country:US
Mailing Address - Phone:863-205-7813
Mailing Address - Fax:
Practice Address - Street 1:14497 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2047
Practice Address - Country:US
Practice Address - Phone:813-814-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician