Provider Demographics
NPI:1962150201
Name:CASTRO SARDINAS, VIVIAN GISELLE
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:GISELLE
Last Name:CASTRO SARDINAS
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 1:3853 NORTHDALE BLVD STE 155
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1861
Mailing Address - Country:US
Mailing Address - Phone:813-539-6326
Mailing Address - Fax:
Practice Address - Street 1:9004 WHEATHILL WAY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-5717
Practice Address - Country:US
Practice Address - Phone:813-539-6326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22-203516106S00000X
FL1-24-74311103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician