Provider Demographics
NPI:1043952039
Name:SANTIAGO, VIVIAN JO
Entity Type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:JO
Last Name:SANTIAGO
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 1:43627 WILD ROSE ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-8605
Mailing Address - Country:US
Mailing Address - Phone:209-621-9262
Mailing Address - Fax:
Practice Address - Street 1:43627 WILD ROSE ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-8605
Practice Address - Country:US
Practice Address - Phone:209-621-9262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty