Provider Demographics
NPI:1174676019
Name:SANTUCCI, GARY JOSEPH (EDS)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:JOSEPH
Last Name:SANTUCCI
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 S UNIVERSITY DR
Mailing Address - Street 2:#115
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-3839
Mailing Address - Country:US
Mailing Address - Phone:954-474-1119
Mailing Address - Fax:954-474-1118
Practice Address - Street 1:4801 S UNIVERSITY DR
Practice Address - Street 2:#115
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-3839
Practice Address - Country:US
Practice Address - Phone:954-474-1119
Practice Address - Fax:954-474-1118
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT0000682106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist