Provider Demographics
NPI:1174993869
Name:CASTILLO, GUILLERMINA
Entity type:Individual
Prefix:
First Name:GUILLERMINA
Middle Name:
Last Name:CASTILLO
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 1:405 N DATE ST STE 8
Mailing Address - Street 2:
Mailing Address - City:T OR C
Mailing Address - State:NM
Mailing Address - Zip Code:87901-2378
Mailing Address - Country:US
Mailing Address - Phone:575-894-7589
Mailing Address - Fax:575-894-7584
Practice Address - Street 1:405 N DATE ST STE 8
Practice Address - Street 2:
Practice Address - City:T OR C
Practice Address - State:NM
Practice Address - Zip Code:87901-2378
Practice Address - Country:US
Practice Address - Phone:575-894-7589
Practice Address - Fax:575-894-7584
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5547235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM5547OtherSTATE LICENSE