Provider Demographics
NPI:1043051816
Name:GONZALEZ CASTELLON, ANGELA YADIRA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:YADIRA
Last Name:GONZALEZ CASTELLON
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 1:730 LYNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-3142
Mailing Address - Country:US
Mailing Address - Phone:786-790-4636
Mailing Address - Fax:
Practice Address - Street 1:730 LYNWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-3142
Practice Address - Country:US
Practice Address - Phone:786-790-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-339638106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty