Provider Demographics
NPI:1962631408
Name:SANTIAGO, MAGALY (MA)
Entity Type:Individual
Prefix:
First Name:MAGALY
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. HACIENDA TOLEDO
Mailing Address - Street 2:E 105 CALLE BARCELONA
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00612
Mailing Address - Country:US
Mailing Address - Phone:787-566-7807
Mailing Address - Fax:
Practice Address - Street 1:URB. HACIENDA TOLEDO
Practice Address - Street 2:E 105 CALLE BARCELONA
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00612
Practice Address - Country:US
Practice Address - Phone:787-566-7807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3452103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1962631408Medicaid
PR1962631408Medicare UPIN
PR1962631408Medicare PIN
PR1962631408Medicare NSC