Provider Demographics
NPI:1659843829
Name:SANTIAGO, GABRIEL (MA)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5103 WILLIAMS FORK TRL APT 108
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3417
Mailing Address - Country:US
Mailing Address - Phone:720-546-2141
Mailing Address - Fax:
Practice Address - Street 1:1501 YARMOUTH AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-0564
Practice Address - Country:US
Practice Address - Phone:720-546-2141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-27
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0107957101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health