Provider Demographics
NPI:1992152557
Name:CASTRO, SAMANTHA L (SAC-IT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:L
Last Name:CASTRO
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E MELVIN AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-3850
Mailing Address - Country:US
Mailing Address - Phone:920-458-6527
Mailing Address - Fax:920-458-6623
Practice Address - Street 1:2842 S BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-6518
Practice Address - Country:US
Practice Address - Phone:920-458-6527
Practice Address - Fax:920-458-6623
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI130-17635101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI101YA0400XMedicaid