Provider Demographics
NPI:1548791650
Name:SANTANA, ROMEO
Entity Type:Individual
Prefix:
First Name:ROMEO
Middle Name:
Last Name:SANTANA
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 1:1260 IROQUOIS AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8549
Mailing Address - Country:US
Mailing Address - Phone:646-280-5093
Mailing Address - Fax:
Practice Address - Street 1:2100 N MAIN ST STE 304
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-1877
Practice Address - Country:US
Practice Address - Phone:574-546-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106E00000X
IN20043350B103TC0700X
IN20043350A103TC0700X
IL071010236103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20043350AOtherLICENSE
IL1548791650OtherLICENSE
IN20043350BOtherLICENSE