Provider Demographics
NPI:1144805391
Name:SANTIAGO, SAMANTHA LUBOV
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LUBOV
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:LUBOV
Other - Last Name:VIRBITSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:945 CARLSON DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3918
Mailing Address - Country:US
Mailing Address - Phone:717-756-1882
Mailing Address - Fax:
Practice Address - Street 1:110 1/2 N TEJON ST STE 204
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1434
Practice Address - Country:US
Practice Address - Phone:719-362-0660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003701235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist