Provider Demographics
NPI:1902497290
Name:CASTILLO, ABIGAIL MATA
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:MATA
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ABIGAIL
Other - Middle Name:REUBEILI
Other - Last Name:MATA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1404 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MCGREGOR
Mailing Address - State:TX
Mailing Address - Zip Code:76657-1937
Mailing Address - Country:US
Mailing Address - Phone:254-420-9074
Mailing Address - Fax:
Practice Address - Street 1:15140 BADGER RANCH BLVD
Practice Address - Street 2:STE 301 & 302
Practice Address - City:WOODWAY
Practice Address - State:TX
Practice Address - Zip Code:76712
Practice Address - Country:US
Practice Address - Phone:254-829-4787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT21150488106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX21150488OtherBACB