Provider Demographics
NPI:1407282387
Name:SANTANA, JUAN CARLOS (MA)
Entity Type:Individual
Prefix:PROF
First Name:JUAN
Middle Name:CARLOS
Last Name:SANTANA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 NORMAN ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-5003
Mailing Address - Country:US
Mailing Address - Phone:413-736-8329
Mailing Address - Fax:413-732-5362
Practice Address - Street 1:2155 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-3301
Practice Address - Country:US
Practice Address - Phone:413-736-0395
Practice Address - Fax:413-734-1651
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3680103TC1900X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1134107113OtherNHP
MA997303OtherNETWORK HEALTH
MA71756OtherTUFTS
MA1134107113OtherFALLON
MA12529OtherHNE
MA1134107113OtherBEACON
MA042622756OtherCCA
MA1134107113OtherMBHP
MA1307576Medicaid
MA042622756OtherCCA