Provider Demographics
NPI:1205232048
Name:SANTOS, JUAN BAUTISTA (MS, CRC, LPCA)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:BAUTISTA
Last Name:SANTOS
Suffix:
Gender:M
Credentials:MS, CRC, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4512 BRANDT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-8445
Mailing Address - Country:US
Mailing Address - Phone:336-707-1723
Mailing Address - Fax:336-774-0007
Practice Address - Street 1:3410 HEALY DR STE 203
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1568
Practice Address - Country:US
Practice Address - Phone:336-707-1723
Practice Address - Fax:133-677-4007
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA11154101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health