Basic Information
| Provider Information | |||||||||
| NPI: | 1639762065 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANG-CASTANEDA | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 BROOK RD | ||||||||
| Address2: | |||||||||
| City: | PORT CHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105733147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146480426 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 GRACE CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | PORT CHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105734911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149378899 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2021 | ||||||||
| LastUpdateDate: | 02/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 103056 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 103056 | 05 | NY | MEDICAID |