Basic Information
| Provider Information | |||||||||
| NPI: | 1649713736 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE CASTRO | ||||||||
| FirstName: | MARIANNE | ||||||||
| MiddleName: | GONZALES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2490 SUN VALLEY CIR | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209062230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2029997944 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 301 RUSSELL AVE | ||||||||
| Address2: | |||||||||
| City: | GAITHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208772800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012164247 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2016 | ||||||||
| LastUpdateDate: | 03/07/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 07548 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1447657507 | 01 | MD | NPI TYPE 2 (ORGANIZATION NPI) | OTHER | 4374045-00 | 05 | MD | MEDICAID |