Provider Demographics
NPI:1679140495
Name:CASTILLO, INEIBIS TAMARA
Entity type:Individual
Prefix:
First Name:INEIBIS
Middle Name:TAMARA
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 1:100 PANSY CT
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-5604
Mailing Address - Country:US
Mailing Address - Phone:407-486-6720
Mailing Address - Fax:
Practice Address - Street 1:2208 W COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-3436
Practice Address - Country:US
Practice Address - Phone:407-261-6255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLRBT-20-123792106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician