Provider Demographics
NPI:1104227974
Name:CASTRO, LILLIAN Q
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:Q
Last Name:CASTRO
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 1:4501 N WILSON WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-2426
Mailing Address - Country:US
Mailing Address - Phone:209-957-9001
Mailing Address - Fax:209-957-9004
Practice Address - Street 1:1341 W ROBINHOOD DR STE B2
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5517
Practice Address - Country:US
Practice Address - Phone:209-957-9001
Practice Address - Fax:209-957-9004
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-10
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF59895106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist