Provider Demographics
NPI:1578982534
Name:SANTIAGO, ENID M
Entity Type:Individual
Prefix:
First Name:ENID
Middle Name:M
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 1:1555 BONAVENTURE BLVD STE 123
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-4041
Mailing Address - Country:US
Mailing Address - Phone:954-612-7771
Mailing Address - Fax:754-701-5539
Practice Address - Street 1:1555 BONAVENTURE BLVD STE 123
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-4041
Practice Address - Country:US
Practice Address - Phone:954-612-7771
Practice Address - Fax:754-701-5539
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13661235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SZ6609OtherFLORIDA BOARD OF SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY