Provider Demographics
NPI:1417301532
Name:SANTOS, EDMUND ROBERTO (BCABA)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:ROBERTO
Last Name:SANTOS
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 MALL RING CIR
Mailing Address - Street 2:SUITE 215
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-6683
Mailing Address - Country:US
Mailing Address - Phone:702-547-6971
Mailing Address - Fax:702-547-6948
Practice Address - Street 1:731 MALL RING CIR
Practice Address - Street 2:SUITE 215
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-6683
Practice Address - Country:US
Practice Address - Phone:702-547-6971
Practice Address - Fax:702-547-6948
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-15-02170103K00000X
NV0-19-9614106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV0-19-9614OtherBACB