Provider Demographics
NPI:1588790158
Name:CASTILLO, KRISTINA NOELLE (LCSW)
Entity type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:NOELLE
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KRISTINA
Other - Middle Name:NOELLE
Other - Last Name:CASTILLO-GOUGH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:240 RED TAIL
Mailing Address - Street 2:SUITES 7&8
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1581
Mailing Address - Country:US
Mailing Address - Phone:716-689-3333
Mailing Address - Fax:
Practice Address - Street 1:240 RED TAIL
Practice Address - Street 2:SUITES 7&8
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1581
Practice Address - Country:US
Practice Address - Phone:716-689-3333
Practice Address - Fax:716-689-9695
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072078-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA2799Medicare ID - Type Unspecified