Provider Demographics
NPI:1619129509
Name:TITLA, SANTANA M
Entity Type:Individual
Prefix:
First Name:SANTANA
Middle Name:M
Last Name:TITLA
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:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:ISLETA
Mailing Address - State:NM
Mailing Address - Zip Code:87022-0640
Mailing Address - Country:US
Mailing Address - Phone:505-869-3200
Mailing Address - Fax:505-869-4584
Practice Address - Street 1:01 SAGEBRUSH STREET
Practice Address - Street 2:
Practice Address - City:ISLETA
Practice Address - State:NM
Practice Address - Zip Code:87022-0640
Practice Address - Country:US
Practice Address - Phone:505-869-3200
Practice Address - Fax:505-869-4584
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0114121101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)