Provider Demographics
NPI:1568170645
Name:LOPEZ MIQUILENA, SANTIAGO E
Entity Type:Individual
Prefix:
First Name:SANTIAGO
Middle Name:E
Last Name:LOPEZ MIQUILENA
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 1:3160 SMOKE SIGNAL CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-4616
Mailing Address - Country:US
Mailing Address - Phone:407-591-7629
Mailing Address - Fax:
Practice Address - Street 1:3501 W VINE ST STE 124
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4660
Practice Address - Country:US
Practice Address - Phone:407-483-3074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician