Provider Demographics
NPI:1003217423
Name:SANTANA, KENNETH (SAC-IT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:SANTANA
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624A W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-2064
Mailing Address - Country:US
Mailing Address - Phone:414-649-1929
Mailing Address - Fax:
Practice Address - Street 1:1111 S 6TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-2301
Practice Address - Country:US
Practice Address - Phone:414-649-1929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17228-130324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility