Provider Demographics
NPI:1609367580
Name:RUBIO SANTIAGO, VIVIANA
Entity Type:Individual
Prefix:
First Name:VIVIANA
Middle Name:
Last Name:RUBIO 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 1:1414 NW 107TH AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33172-2739
Mailing Address - Country:US
Mailing Address - Phone:786-762-2952
Mailing Address - Fax:786-762-2953
Practice Address - Street 1:1414 NW 107TH AVE STE 109
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:FL
Practice Address - Zip Code:33172-2739
Practice Address - Country:US
Practice Address - Phone:786-762-2952
Practice Address - Fax:786-762-2953
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1598103TS0200X
FLCCM100334104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker