Basic Information
Provider Information | |||||||||
NPI: | 1790892701 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CASTILLO | ||||||||
FirstName: | MARIA | ||||||||
MiddleName: | CARMEN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6527 MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | TRUMBULL | ||||||||
State: | CT | ||||||||
PostalCode: | 06611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2034458966 | ||||||||
FaxNumber: | 2032613492 | ||||||||
Practice Location | |||||||||
Address1: | 21444 CARMEAN WAY | ||||||||
Address2: |   | ||||||||
City: | GEORGETOWN | ||||||||
State: | DE | ||||||||
PostalCode: | 199474572 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3028551233 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2006 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 002629 | CT | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | Q1-0001532 | DE | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | Q1-0001532 | 01 | DE | LCSW | OTHER |