Provider Demographics
NPI:1225404163
Name:SANTIAGO, TANYA NICOLE
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:NICOLE
Last Name: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 1:325 E 1875 S
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-2614
Mailing Address - Country:US
Mailing Address - Phone:801-687-8564
Mailing Address - Fax:
Practice Address - Street 1:1672 W 700 S STE D
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-4963
Practice Address - Country:US
Practice Address - Phone:801-489-9721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT794620435011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical