Provider Demographics
NPI:1245120062
Name:CASTRO HEREDIA, GREGORIO
Entity type:Individual
Prefix:
First Name:GREGORIO
Middle Name:
Last Name:CASTRO HEREDIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 E TOWNE BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-3731
Mailing Address - Country:US
Mailing Address - Phone:305-515-0109
Mailing Address - Fax:
Practice Address - Street 1:4111 E TOWNE BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3731
Practice Address - Country:US
Practice Address - Phone:305-515-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-03
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11405-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health