Provider Demographics
NPI:1073396826
Name:SANTIAGO LARACUENTE, EMANUEL
Entity Type:Individual
Prefix:
First Name:EMANUEL
Middle Name:
Last Name:SANTIAGO LARACUENTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 BRANCHVIEW DR NE STE 215
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2239
Mailing Address - Country:US
Mailing Address - Phone:704-780-4271
Mailing Address - Fax:
Practice Address - Street 1:900 BRANCHVIEW DR NE STE 215
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2239
Practice Address - Country:US
Practice Address - Phone:704-780-4271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician