Provider Demographics
NPI:1336627256
Name:SANTO, CRYSTAL MARY (COTA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MARY
Last Name:SANTO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 BEACH DR
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712-1603
Mailing Address - Country:US
Mailing Address - Phone:203-868-5206
Mailing Address - Fax:
Practice Address - Street 1:48 BEACH DR
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1603
Practice Address - Country:US
Practice Address - Phone:203-868-5206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001829224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001829Medicaid