Provider Demographics
NPI:1518149889
Name:SANTIAGO, LARRY BOADO
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:BOADO
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 1:5140 DIAMOND HEIGHTS BLVD APT 105A
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94131-1747
Mailing Address - Country:US
Mailing Address - Phone:925-331-0528
Mailing Address - Fax:
Practice Address - Street 1:2086 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4902
Practice Address - Country:US
Practice Address - Phone:925-827-0212
Practice Address - Fax:925-827-1122
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA96681106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1922162999OtherCOMMUNITYBEHAVIORALHEALTH