Provider Demographics
NPI:1083043590
Name:SANTIAGO OLIVO, LAURA C
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:C
Last Name:SANTIAGO OLIVO
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 1:8822 MUGWORT DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-2485
Mailing Address - Country:US
Mailing Address - Phone:787-478-5478
Mailing Address - Fax:
Practice Address - Street 1:476 THUMPER DR
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-4859
Practice Address - Country:US
Practice Address - Phone:787-478-5478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-1478235Z00000X
FLSA19595235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX42011829OtherDMV