Provider Demographics
NPI:1588472674
Name:CASTILLO FUNDORA, ERICK
Entity type:Individual
Prefix:
First Name:ERICK
Middle Name:
Last Name:CASTILLO FUNDORA
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 1:106 SE 9TH CT APT 101
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-7174
Mailing Address - Country:US
Mailing Address - Phone:786-716-1469
Mailing Address - Fax:
Practice Address - Street 1:106 SE 9TH CT APT 101
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-7174
Practice Address - Country:US
Practice Address - Phone:786-716-1469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-21
Last Update Date:2024-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-374692106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician