Basic Information
| Provider Information | |||||||||
| NPI: | 1306316872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASTANEDA | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | LUIS | ||||||||
| NamePrefix: | |||||||||
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| Credential: | BCBA 1-21-50959 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 399318 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941399318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8665234268 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5501 ANTIQUE ROSE WAY | ||||||||
| Address2: | |||||||||
| City: | RIVERBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953679505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095224789 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2018 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | 1-21-50959 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.