Provider Demographics
NPI:1407297286
Name:SANTOS, EDWARD LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LEE
Last Name:SANTOS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 W SOLEDAD AVE
Mailing Address - Street 2:SUTIE 702
Mailing Address - City:HAGATNA
Mailing Address - State:GU
Mailing Address - Zip Code:96910-5061
Mailing Address - Country:US
Mailing Address - Phone:671-483-1017
Mailing Address - Fax:671-477-1077
Practice Address - Street 1:414 W SOLEDAD AVE
Practice Address - Street 2:SUTIE 702
Practice Address - City:HAGATNA
Practice Address - State:GU
Practice Address - Zip Code:96910-5061
Practice Address - Country:US
Practice Address - Phone:671-483-1017
Practice Address - Fax:671-477-1077
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUIMF-85106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist