Provider Demographics
NPI:1184901761
Name:ESTRADA, SANTIAGO (PHD)
Entity type:Individual
Prefix:DR
First Name:SANTIAGO
Middle Name:
Last Name:ESTRADA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31462 FLYING CLOUD DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2754
Mailing Address - Country:US
Mailing Address - Phone:949-493-4423
Mailing Address - Fax:
Practice Address - Street 1:30011 IVY GLENN DR STE 220
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-5018
Practice Address - Country:US
Practice Address - Phone:949-497-4373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12022103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical