Provider Demographics
NPI:1013226083
Name:SANTIAGO, EDWARD (MA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PMB 79 P.O. BOX 5103
Mailing Address - Street 2:
Mailing Address - City:CABO ROJO
Mailing Address - State:PR
Mailing Address - Zip Code:00623
Mailing Address - Country:US
Mailing Address - Phone:787-834-2115
Mailing Address - Fax:
Practice Address - Street 1:410 AVE HOSTOS
Practice Address - Street 2:SUITE 6
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00682-1560
Practice Address - Country:US
Practice Address - Phone:787-834-2115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1589103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling