Provider Demographics
NPI:1437536190
Name:SANTIAGO, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 WREN LN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-6797
Mailing Address - Country:US
Mailing Address - Phone:972-921-1833
Mailing Address - Fax:
Practice Address - Street 1:101 SUMMIT AVE
Practice Address - Street 2:APT 414
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-2618
Practice Address - Country:US
Practice Address - Phone:682-730-0004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210931224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant