Provider Demographics
NPI:1679008643
Name:SANTIS, GARY ALEXANDER
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ALEXANDER
Last Name:SANTIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 MORENA BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3844
Mailing Address - Country:US
Mailing Address - Phone:619-276-8112
Mailing Address - Fax:
Practice Address - Street 1:1202 MORENA BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3844
Practice Address - Country:US
Practice Address - Phone:619-276-8112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA134828106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist