Provider Demographics
NPI:1609154947
Name:SANTIAGO, MARIA TERESA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:TERESA
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 1:3368 NW 64TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-1616
Mailing Address - Country:US
Mailing Address - Phone:954-918-0315
Mailing Address - Fax:
Practice Address - Street 1:18490 JOHNSON ST UNIT EFGH
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-3699
Practice Address - Country:US
Practice Address - Phone:754-264-8779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-18-29241103K00000X
222Q00000X, 390200000X
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program