Provider Demographics
NPI:1356651830
Name:SANTIAGO MARTINEZ, IDRIS ANGELLICE (MSW)
Entity Type:Individual
Prefix:MISS
First Name:IDRIS
Middle Name:ANGELLICE
Last Name:SANTIAGO MARTINEZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MISS
Other - First Name:IDRIS
Other - Middle Name:SANTIAGO
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:HC03BOX11447
Mailing Address - Street 2:
Mailing Address - City:PENUELAS
Mailing Address - State:PR
Mailing Address - Zip Code:00624-9513
Mailing Address - Country:US
Mailing Address - Phone:787-590-4375
Mailing Address - Fax:
Practice Address - Street 1:HC03BOX11447
Practice Address - Street 2:
Practice Address - City:PENUELAS
Practice Address - State:PR
Practice Address - Zip Code:00624-9513
Practice Address - Country:US
Practice Address - Phone:787-590-4375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR100021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical