Provider Demographics
NPI:1124635230
Name:CASTILLO, GABRIEL RAY
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:RAY
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 PHEASANT RUN DR SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-8194
Mailing Address - Country:US
Mailing Address - Phone:505-300-8357
Mailing Address - Fax:
Practice Address - Street 1:9019 WASHINGTON ST NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2435
Practice Address - Country:US
Practice Address - Phone:505-856-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician