Provider Demographics
NPI:1508422049
Name:SANTIAGO, BLANCA IRIS (LCSW)
Entity Type:Individual
Prefix:
First Name:BLANCA
Middle Name:IRIS
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 PINE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3861
Mailing Address - Country:US
Mailing Address - Phone:207-749-4598
Mailing Address - Fax:
Practice Address - Street 1:23 PINE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3861
Practice Address - Country:US
Practice Address - Phone:207-749-4598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC174121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty