Provider Demographics
NPI:1164299749
Name:GARY J. SANTUCCI, ED.S.,P.A.
Entity Type:Organization
Organization Name:GARY J. SANTUCCI, ED.S.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SANTUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:EDS
Authorized Official - Phone:954-474-1119
Mailing Address - Street 1:4801 S UNIVERSITY DR STE 238
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-3836
Mailing Address - Country:US
Mailing Address - Phone:954-474-1119
Mailing Address - Fax:954-474-1118
Practice Address - Street 1:4801 S UNIVERSITY DR STE 238
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-3836
Practice Address - Country:US
Practice Address - Phone:954-474-1119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty