Provider Demographics
NPI:1851529366
Name:DECASTRO, WILHELMINA RAMOS
Entity type:Individual
Prefix:
First Name:WILHELMINA
Middle Name:RAMOS
Last Name:DECASTRO
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 1:12420 VENICE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3841
Mailing Address - Country:US
Mailing Address - Phone:310-751-1200
Mailing Address - Fax:
Practice Address - Street 1:204 HAMPTON DR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2623
Practice Address - Country:US
Practice Address - Phone:310-396-6468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA288821041C0700X
CA26394104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No104100000XBehavioral Health & Social Service ProvidersSocial Worker