Provider Demographics
NPI:1487461323
Name:CASTOR, ANNALISE
Entity type:Individual
Prefix:
First Name:ANNALISE
Middle Name:
Last Name:CASTOR
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 1:11028 MOUNT ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-4484
Mailing Address - Country:US
Mailing Address - Phone:702-501-1311
Mailing Address - Fax:
Practice Address - Street 1:4455 ALLEN LN
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-2204
Practice Address - Country:US
Practice Address - Phone:702-385-1072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health