Provider Demographics
NPI:1578733077
Name:SANTISTEBAN, JUANCARLOS
Entity Type:Individual
Prefix:MR
First Name:JUANCARLOS
Middle Name:
Last Name:SANTISTEBAN
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 1:2404 N 3400 W # B
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84404-8579
Mailing Address - Country:US
Mailing Address - Phone:801-458-8408
Mailing Address - Fax:
Practice Address - Street 1:2404 N 3400 W # B
Practice Address - Street 2:
Practice Address - City:PLAIN CITY
Practice Address - State:UT
Practice Address - Zip Code:84404-8579
Practice Address - Country:US
Practice Address - Phone:801-458-8408
Practice Address - Fax:801-458-8408
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9090848-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist