Provider Demographics
NPI:1598485179
Name:SANTIAGO, KIYANA NICHOLE
Entity Type:Individual
Prefix:
First Name:KIYANA
Middle Name:NICHOLE
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 1:50 SUNSET LN
Mailing Address - Street 2:
Mailing Address - City:PAXTON
Mailing Address - State:MA
Mailing Address - Zip Code:01612-1106
Mailing Address - Country:US
Mailing Address - Phone:857-258-7704
Mailing Address - Fax:
Practice Address - Street 1:50 SUNSET LN
Practice Address - Street 2:
Practice Address - City:PAXTON
Practice Address - State:MA
Practice Address - Zip Code:01612-1106
Practice Address - Country:US
Practice Address - Phone:857-258-7704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent