Provider Demographics
NPI:1447817556
Name:CASTILLO-FUNDORA, EVELYN THERESA (LSP, EDS)
Entity type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:THERESA
Last Name:CASTILLO-FUNDORA
Suffix:
Gender:F
Credentials:LSP, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13101 SW 84TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-4323
Mailing Address - Country:US
Mailing Address - Phone:305-302-4776
Mailing Address - Fax:
Practice Address - Street 1:13101 SW 84TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-4323
Practice Address - Country:US
Practice Address - Phone:305-302-4776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH21845101YM0800X
FLSS1395103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health