Provider Demographics
NPI:1114749512
Name:CASTILLO, BREANNA RAVEN
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:RAVEN
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 1:2285 W M 61
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-8401
Mailing Address - Country:US
Mailing Address - Phone:989-600-6902
Mailing Address - Fax:
Practice Address - Street 1:1234 W CEDAR AVE
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-1818
Practice Address - Country:US
Practice Address - Phone:989-709-5413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician