Provider Demographics
NPI:1306503115
Name:CASTILLO, JOSE LUIS
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
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 1:815 COTTON BAY DR W APT 908
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-9090
Mailing Address - Country:US
Mailing Address - Phone:787-368-7590
Mailing Address - Fax:
Practice Address - Street 1:850 NW FEDERAL HWY STE 173
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-1019
Practice Address - Country:US
Practice Address - Phone:772-362-9878
Practice Address - Fax:772-362-9879
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21-194530106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC234-432-81-029-0OtherLICENSE