Provider Demographics
NPI:1205634813
Name:CASTILLEJOS, MIRIAM NATALY
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:NATALY
Last Name:CASTILLEJOS
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 1:1512 GARY CT
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-4819
Mailing Address - Country:US
Mailing Address - Phone:707-236-7123
Mailing Address - Fax:
Practice Address - Street 1:3223 PRIMROSE AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-7723
Practice Address - Country:US
Practice Address - Phone:707-542-5195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220146514101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool