Provider Demographics
NPI:1255029070
Name:SANTIBANEZ, CLARISSA MARIE
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:MARIE
Last Name:SANTIBANEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 ELMONT DR APT 1524A
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-1775
Mailing Address - Country:US
Mailing Address - Phone:210-630-3967
Mailing Address - Fax:
Practice Address - Street 1:1250 S A W GRIMES BLVD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-2854
Practice Address - Country:US
Practice Address - Phone:512-677-9339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician