Provider Demographics
NPI:1184197261
Name:DE SANTIAGO, MYRNA A
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:A
Last Name:DE SANTIAGO
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 1:113 LUNA DR
Mailing Address - Street 2:
Mailing Address - City:SUNLAND PARK
Mailing Address - State:NM
Mailing Address - Zip Code:88063-9299
Mailing Address - Country:US
Mailing Address - Phone:915-892-3763
Mailing Address - Fax:
Practice Address - Street 1:113 LUNA DR
Practice Address - Street 2:
Practice Address - City:SUNLAND PARK
Practice Address - State:NM
Practice Address - Zip Code:88063-9299
Practice Address - Country:US
Practice Address - Phone:915-892-3763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician