Provider Demographics
NPI:1851023030
Name:SANTOS, JUSTIN (MT-BC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SANTOS
Suffix:
Gender:M
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7821 KELLY CIR
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1646
Mailing Address - Country:US
Mailing Address - Phone:562-412-5760
Mailing Address - Fax:
Practice Address - Street 1:16800 ASTON
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-4812
Practice Address - Country:US
Practice Address - Phone:949-748-8571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17206225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic TherapistGroup - Single Specialty