Provider Demographics
NPI:1376751198
Name:MILLET SANTIAGO, IVELISSE (MSPT)
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:MILLET SANTIAGO
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 141024
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00614-1024
Mailing Address - Country:US
Mailing Address - Phone:787-544-6888
Mailing Address - Fax:787-544-6888
Practice Address - Street 1:462 ATLANTIC VIEW BUILDING SUITE 2
Practice Address - Street 2:MARGINAL CARRIZALES
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659-2525
Practice Address - Country:US
Practice Address - Phone:787-544-6888
Practice Address - Fax:787-544-6888
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1349225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0059432Medicare PIN