Provider Demographics
NPI:1316371727
Name:SANTIAGO, SARA NICOLE
Entity Type:Individual
Prefix:
First Name:SARA
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 1:3800 DALECREST DR UNIT 1054
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-1762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3800 DALECREST DR UNIT 1054
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-1762
Practice Address - Country:US
Practice Address - Phone:702-541-2567
Practice Address - Fax:702-541-2567
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV0614Medicaid
NV0614Medicaid
NV1013359515Medicare PIN
NV1013359515Medicare UPIN
1013359515Medicare Oscar/Certification