Provider Demographics
NPI:1871311969
Name:CASTRO-MEDINA, WANDA IVELISSE (MS)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:IVELISSE
Last Name:CASTRO-MEDINA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 DYANEZ ST
Mailing Address - Street 2:
Mailing Address - City:MERCEDES
Mailing Address - State:TX
Mailing Address - Zip Code:78570-5045
Mailing Address - Country:US
Mailing Address - Phone:210-947-4024
Mailing Address - Fax:
Practice Address - Street 1:115 DYANEZ ST
Practice Address - Street 2:
Practice Address - City:MERCEDES
Practice Address - State:TX
Practice Address - Zip Code:78570-5045
Practice Address - Country:US
Practice Address - Phone:210-947-4024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-28
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX84707101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional