Provider Demographics
NPI:1649390535
Name:SANTIAGO-SOTO, MARISOL (BA)
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:SANTIAGO-SOTO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4790 80TH TER
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-2423
Mailing Address - Country:US
Mailing Address - Phone:727-545-3595
Mailing Address - Fax:727-545-3595
Practice Address - Street 1:480 7TH AVE S
Practice Address - Street 2:DEPT 7470
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4839
Practice Address - Country:US
Practice Address - Phone:727-767-4403
Practice Address - Fax:727-767-4715
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL768038400Medicaid