Provider Demographics
NPI:1962046748
Name:CASTILLO, LEIAH ROXANN (LMT)
Entity type:Individual
Prefix:
First Name:LEIAH
Middle Name:ROXANN
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 MOORING BUOY
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29928-5223
Mailing Address - Country:US
Mailing Address - Phone:843-301-1345
Mailing Address - Fax:
Practice Address - Street 1:113 WAPPOO CREEK DR STE 2
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-2136
Practice Address - Country:US
Practice Address - Phone:843-301-1345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11856225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist