Basic Information
| Provider Information | |||||||||
| NPI: | 1639704125 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASTILLO | ||||||||
| FirstName: | WYLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15880 NW 14TH RD | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330281653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548049383 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5707 N 22ND ST | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336104350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132398069 | ||||||||
| FaxNumber: | 8132317324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2020 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.