Provider Demographics
NPI:1124138300
Name:CASTRO, JILL SARIE (PSYD, LLP)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:SARIE
Last Name:CASTRO
Suffix:
Gender:F
Credentials:PSYD, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26105 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-4576
Mailing Address - Country:US
Mailing Address - Phone:248-229-8388
Mailing Address - Fax:
Practice Address - Street 1:26105 ORCHARD LAKE RD
Practice Address - Street 2:SUITE 204
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-4576
Practice Address - Country:US
Practice Address - Phone:248-229-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013351103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G46345Medicare ID - Type UnspecifiedBLUE WATER MENTAL HEALTH