Provider Demographics
NPI:1568841724
Name:SANTIAGO, BRUNILDA
Entity Type:Individual
Prefix:
First Name:BRUNILDA
Middle Name:
Last Name:SANTIAGO
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 1:16956 24TH RD
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-4128
Mailing Address - Country:US
Mailing Address - Phone:718-352-8505
Mailing Address - Fax:
Practice Address - Street 1:16956 24TH RD
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-4128
Practice Address - Country:US
Practice Address - Phone:718-352-8505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244019Medicaid