Provider Demographics
NPI:1922090760
Name:SANTIAGO-GOMEZ, EVELIA MARGARITA (LCSWR)
Entity Type:Individual
Prefix:MS
First Name:EVELIA
Middle Name:MARGARITA
Last Name:SANTIAGO-GOMEZ
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2519 BRUYNSWICK RD
Mailing Address - Street 2:
Mailing Address - City:WALLKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12589-3244
Mailing Address - Country:US
Mailing Address - Phone:845-476-9800
Mailing Address - Fax:
Practice Address - Street 1:2519 BRUYNSWICK RD
Practice Address - Street 2:
Practice Address - City:WALLKILL
Practice Address - State:NY
Practice Address - Zip Code:12589-3244
Practice Address - Country:US
Practice Address - Phone:845-476-9800
Practice Address - Fax:845-744-6793
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0521841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY052184-1OtherLCSWR LICENSE
NU8261Medicare ID - Type Unspecified