Basic Information
| Provider Information | |||||||||
| NPI: | 1104200385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASTILLO | ||||||||
| FirstName: | DIVINA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5030 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100341609 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4419 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104572562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183647700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2015 | ||||||||
| LastUpdateDate: | 04/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 094650 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 092892 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 8921812 | 01 | NY | BEHAVIORAL SPECIALIST | OTHER |