Provider Demographics
NPI:1982967584
Name:CASTILLO, LISA MARIE (MS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:100 GLEN COVE AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2818
Mailing Address - Country:US
Mailing Address - Phone:516-609-2000
Mailing Address - Fax:
Practice Address - Street 1:100 GLEN COVE AVE
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2818
Practice Address - Country:US
Practice Address - Phone:516-609-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist