Provider Demographics
NPI:1376304261
Name:DELOS SANTOS, DEREK (CASAC T)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:DELOS SANTOS
Suffix:
Gender:M
Credentials:CASAC T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:764 E 176TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-4606
Mailing Address - Country:US
Mailing Address - Phone:718-583-5150
Mailing Address - Fax:
Practice Address - Street 1:764 E 176TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-4606
Practice Address - Country:US
Practice Address - Phone:718-583-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY38783101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)