Provider Demographics
NPI:1073185450
Name:SANTIAGO, KRYSTINE FAITH MENDOZA
Entity Type:Individual
Prefix:MISS
First Name:KRYSTINE FAITH
Middle Name:MENDOZA
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 1:628 W 235TH ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-5130
Mailing Address - Country:US
Mailing Address - Phone:310-989-0259
Mailing Address - Fax:
Practice Address - Street 1:24331 ANDREA ST
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92656-3102
Practice Address - Country:US
Practice Address - Phone:949-954-4422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician