Basic Information
| Provider Information | |||||||||
| NPI: | 1649361619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASTILLO | ||||||||
| FirstName: | CAROLINA | ||||||||
| MiddleName: | HEATHER | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFTI 63884 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CALLANDER | ||||||||
| OtherFirstName: | CAROLINA | ||||||||
| OtherMiddleName: | HEATHER | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2100 5TH STREET | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307473496 | ||||||||
| FaxNumber: | 5307530398 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 5TH STREET | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307473496 | ||||||||
| FaxNumber: | 5307530398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 06/03/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFTI 45112 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 390200000X | 63884(MFTI) | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.