Provider Demographics
NPI:1689471591
Name:CASTON, CONNIE L
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:CASTON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8920 EVES RD UNIT 769511
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-0128
Mailing Address - Country:US
Mailing Address - Phone:414-699-7433
Mailing Address - Fax:
Practice Address - Street 1:8920 EVES RD UNIT 769511
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-0128
Practice Address - Country:US
Practice Address - Phone:414-699-7433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT014048225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist