Provider Demographics
NPI:1699279315
Name:CASTELLO, BROOKE (MS ED,)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:
Last Name:CASTELLO
Suffix:
Gender:F
Credentials:MS ED,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 RAYNOR RD
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-1904
Mailing Address - Country:US
Mailing Address - Phone:631-379-4104
Mailing Address - Fax:
Practice Address - Street 1:1355 STONY BROOK RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2203
Practice Address - Country:US
Practice Address - Phone:631-285-6400
Practice Address - Fax:631-285-6523
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1109269171174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist