Provider Demographics
NPI:1598079808
Name:SANTIAGO, VIVIAN (MA)
Entity Type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PASEO DE LA CEIBA, #109, POMARROSA STREET
Mailing Address - Street 2:
Mailing Address - City:JUNCOS
Mailing Address - State:PR
Mailing Address - Zip Code:00777
Mailing Address - Country:US
Mailing Address - Phone:787-633-6768
Mailing Address - Fax:
Practice Address - Street 1:AVE. MIGUEL MELENDEZ MUNOS, #14
Practice Address - Street 2:
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736
Practice Address - Country:US
Practice Address - Phone:787-633-6768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3052103T00000X, 103TC1900X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent