Provider Demographics
NPI:1891522447
Name:CASTRO, JUAN (CLINICIAN)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:CASTRO
Suffix:
Gender:M
Credentials:CLINICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6030 AVENORRA DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2231
Mailing Address - Country:US
Mailing Address - Phone:858-449-8593
Mailing Address - Fax:
Practice Address - Street 1:3255 WING ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4638
Practice Address - Country:US
Practice Address - Phone:619-241-0608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142960106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist