Provider Demographics
NPI:1750026753
Name:SANTIAGO, MARIA IRENE
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:IRENE
Last Name:SANTIAGO
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 1:30842 WINDY RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-6891
Mailing Address - Country:US
Mailing Address - Phone:323-574-1224
Mailing Address - Fax:
Practice Address - Street 1:30842 WINDY RIDGE WAY
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-6891
Practice Address - Country:US
Practice Address - Phone:323-574-1224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA752731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA75273OtherLICENSED CLINICAL SOCIAL WORKER
CA68379OtherCALIFORNIA CHILDREN'S SERVICES PROGRAM PANELED