Provider Demographics
NPI:1205107554
Name:CASTILLO, BRENDA L (SLP)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:L
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9300 BLACK FARM LN NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5953
Mailing Address - Country:US
Mailing Address - Phone:505-341-0376
Mailing Address - Fax:
Practice Address - Street 1:4216 BALLOON PARK RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5801
Practice Address - Country:US
Practice Address - Phone:505-344-5470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2805235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist