Basic Information
Provider Information | |||||||||
NPI: | 1386947471 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CASTRO | ||||||||
FirstName: | JOAQUIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5628 E SLAUSON AVE | ||||||||
Address2: |   | ||||||||
City: | COMMERCE | ||||||||
State: | CA | ||||||||
PostalCode: | 900402922 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3233996564 | ||||||||
FaxNumber: | 3238329224 | ||||||||
Practice Location | |||||||||
Address1: | 2450 S ATLANTIC BLVD | ||||||||
Address2: | SUITE 101 | ||||||||
City: | COMMERCE | ||||||||
State: | CA | ||||||||
PostalCode: | 900401200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3233189960 | ||||||||
FaxNumber: | 3237803211 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/10/2010 | ||||||||
LastUpdateDate: | 02/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.