Basic Information
| Provider Information | |||||||||
| NPI: | 1164088720 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASTILLO | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 345A GREENWOOD ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016071753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083630200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 345A GREENWOOD ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016071753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083630200 | ||||||||
| FaxNumber: | 5083631213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2019 | ||||||||
| LastUpdateDate: | 05/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.