Provider Demographics
NPI:1841984226
Name:CASTRO, GRACIELA CRUZ
Entity type:Individual
Prefix:
First Name:GRACIELA
Middle Name:CRUZ
Last Name: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 1:14320 PALM DR
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-6874
Mailing Address - Country:US
Mailing Address - Phone:760-770-2264
Mailing Address - Fax:760-770-2230
Practice Address - Street 1:14320 PALM DR
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-6874
Practice Address - Country:US
Practice Address - Phone:760-770-2264
Practice Address - Fax:760-770-2230
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CAMPSS-BUTINA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker