Provider Demographics
NPI:1639418080
Name:DE LOS SANTOS, MARISOL
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:DE LOS SANTOS
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 1:172 E 205TH ST APT 2F10458
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-1233
Mailing Address - Country:US
Mailing Address - Phone:917-484-3711
Mailing Address - Fax:
Practice Address - Street 1:172 E 205TH ST APT 2F10458
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-1233
Practice Address - Country:US
Practice Address - Phone:917-484-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1112453103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY705065131OtherTEACHER CERTIFICATION SPECIAL EDUCATION BIRTH-SENCOND GRADE
NY644174121OtherTEACHER CERTIFICATION GENERAL ED- BIRTH -SECOND GRADE