Provider Demographics
NPI:1336673151
Name:SANTIAGO, MA. CARMELA
Entity Type:Individual
Prefix:
First Name:MA. CARMELA
Middle Name:
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 1:2070 CUTTERPOINT DR
Mailing Address - Street 2:UNIT 204
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-4569
Mailing Address - Country:US
Mailing Address - Phone:704-458-3997
Mailing Address - Fax:
Practice Address - Street 1:2070 CUTTERPOINT DR
Practice Address - Street 2:UNIT 204
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-4569
Practice Address - Country:US
Practice Address - Phone:704-458-3997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP15095225100000X
SC7579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist