Provider Demographics
NPI:1760154637
Name:SANTIAGO, JOHANNA ROSALEE (CCM)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:ROSALEE
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 BOSTON RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01119-1332
Mailing Address - Country:US
Mailing Address - Phone:413-459-0456
Mailing Address - Fax:
Practice Address - Street 1:935 BOSTON RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01119-1332
Practice Address - Country:US
Practice Address - Phone:413-459-0456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty