Provider Demographics
NPI:1497101109
Name:SANTIAGO-BOSTON, LETICIA I
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:I
Last Name:SANTIAGO-BOSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 TOWNSEND AVE
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08009-9011
Mailing Address - Country:US
Mailing Address - Phone:609-267-1550
Mailing Address - Fax:609-534-9194
Practice Address - Street 1:100 TOWNSEND AVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08009-9011
Practice Address - Country:US
Practice Address - Phone:609-267-1550
Practice Address - Fax:609-534-9194
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NJ37AC00451100101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health