Provider Demographics
NPI:1205116381
Name:MATOS SANTIAGO, CHAGO V (PHD)
Entity type:Individual
Prefix:DR
First Name:CHAGO
Middle Name:V
Last Name:MATOS SANTIAGO
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:ITURREGUI PLAZA 65 INFANTERIA
Mailing Address - Street 2:SUITE 217-B
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00924
Mailing Address - Country:US
Mailing Address - Phone:787-701-2626
Mailing Address - Fax:787-768-8094
Practice Address - Street 1:ITURREGUI PLAZA 65 INFANTERIA
Practice Address - Street 2:SUITE 217-B
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924
Practice Address - Country:US
Practice Address - Phone:787-701-2626
Practice Address - Fax:787-768-8094
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4014103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical