Provider Demographics
NPI:1245570647
Name:SANTOS, DEBBI WAGNER (MS BCABA)
Entity Type:Individual
Prefix:MS
First Name:DEBBI
Middle Name:WAGNER
Last Name:SANTOS
Suffix:
Gender:F
Credentials:MS BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 SAINT JOHNS ST
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7241
Mailing Address - Country:US
Mailing Address - Phone:772-713-6978
Mailing Address - Fax:
Practice Address - Street 1:4890 WAGON MASTER TRL
Practice Address - Street 2:
Practice Address - City:MICCO
Practice Address - State:FL
Practice Address - Zip Code:32976-2736
Practice Address - Country:US
Practice Address - Phone:772-664-1620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-02-0614103K00000X
FL103K00000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst