Provider Demographics
NPI:1962930750
Name:CASTELLANOS, NICOLE GISELA
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:GISELA
Last Name:CASTELLANOS
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 1:6416 NW 5TH WAY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-6112
Mailing Address - Country:US
Mailing Address - Phone:888-754-0398
Mailing Address - Fax:
Practice Address - Street 1:18220 SW 97TH AVE
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-5502
Practice Address - Country:US
Practice Address - Phone:786-592-1574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-52103106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021115700Medicaid