Provider Demographics
NPI:1013332717
Name:SANTOS, JOSE MATIAS III (LPC)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:MATIAS
Last Name:SANTOS
Suffix:III
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-2935
Mailing Address - Country:US
Mailing Address - Phone:214-764-6333
Mailing Address - Fax:972-441-2383
Practice Address - Street 1:212 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-2935
Practice Address - Country:US
Practice Address - Phone:214-764-6333
Practice Address - Fax:972-441-2385
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-04
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69085101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health