Provider Demographics
NPI:1821506809
Name:JUAN SANTOS, SHEILA
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:JUAN SANTOS
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 1:16782 VON KARMAN AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-2417
Mailing Address - Country:US
Mailing Address - Phone:855-223-7123
Mailing Address - Fax:
Practice Address - Street 1:1295 CORONA POINTE CT STE 102
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1721
Practice Address - Country:US
Practice Address - Phone:855-223-7123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-21-52701103K00000X
CARBT-17-3573-56155106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician