Provider Demographics
NPI:1255184065
Name:SANTIAGO, GABRIEL ANTONIO
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ANTONIO
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4032 BARNSLEY DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812-8118
Mailing Address - Country:US
Mailing Address - Phone:863-558-6902
Mailing Address - Fax:
Practice Address - Street 1:6953 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-6710
Practice Address - Country:US
Practice Address - Phone:407-543-8356
Practice Address - Fax:407-264-6443
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-338807106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician