Provider Demographics
NPI:1164138681
Name:SANTIAGO, AVELINA C (CSAC, CADTP)
Entity Type:Individual
Prefix:
First Name:AVELINA
Middle Name:C
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:CSAC, CADTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N 12TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-3437
Mailing Address - Country:US
Mailing Address - Phone:808-450-0428
Mailing Address - Fax:
Practice Address - Street 1:976 LENZEN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-2737
Practice Address - Country:US
Practice Address - Phone:408-792-3720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14391101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)