Provider Demographics
NPI:1063928992
Name:CASTILLO, LETICIA
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-4031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1413 PACIFIC ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-4031
Practice Address - Country:US
Practice Address - Phone:702-430-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health