Provider Demographics
NPI:1720782063
Name:CASILLAS, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:CASILLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 S PALMETTO AVE APT 105
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-2254
Mailing Address - Country:US
Mailing Address - Phone:203-808-0402
Mailing Address - Fax:
Practice Address - Street 1:1910 S PALMETTO AVE APT 105
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-2254
Practice Address - Country:US
Practice Address - Phone:203-808-0402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-29
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician