Provider Demographics
NPI:1841503117
Name:CASTILLO, CRYSTAL PAULINE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:PAULINE
Last Name:CASTILLO
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 1:12320 WHISTLER ST
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5550
Mailing Address - Country:US
Mailing Address - Phone:909-800-4796
Mailing Address - Fax:
Practice Address - Street 1:12320 WHISTLER ST
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5550
Practice Address - Country:US
Practice Address - Phone:909-800-4796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041S0200X
CA665531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool