Provider Demographics
NPI:1346719242
Name:SANTOS, MICHAEL ERNESTO (BCBA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ERNESTO
Last Name:SANTOS
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 N WINCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1150
Mailing Address - Country:US
Mailing Address - Phone:408-709-9214
Mailing Address - Fax:
Practice Address - Street 1:1360 N WINCHESTER BLVD STE 5
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1150
Practice Address - Country:US
Practice Address - Phone:408-709-9214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2022-08-04
Deactivation Date:2022-05-16
Deactivation Code:
Reactivation Date:2022-08-04
Provider Licenses
StateLicense IDTaxonomies
BACB391258103K00000X
CARBT-17-39306106S00000X
1-20-44469103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician