Provider Demographics
NPI:1114737152
Name:HERRERA CASTILLO, TAILY
Entity type:Individual
Prefix:
First Name:TAILY
Middle Name:
Last Name:HERRERA 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 1:5945 SE 95TH TRL
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974-1483
Mailing Address - Country:US
Mailing Address - Phone:863-484-4800
Mailing Address - Fax:
Practice Address - Street 1:550 SE PORT ST LUCIE BLVD STE 3
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-5108
Practice Address - Country:US
Practice Address - Phone:772-202-0173
Practice Address - Fax:772-209-7631
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-11
Last Update Date:2025-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-396786106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician