Provider Demographics
NPI:1740488634
Name:SANTIAGO, MERCEDES (PTA)
Entity type:Individual
Prefix:
First Name:MERCEDES
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 WILLOUGHBY AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-2710
Mailing Address - Country:US
Mailing Address - Phone:646-279-3062
Mailing Address - Fax:
Practice Address - Street 1:15715 19TH AVE
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-3820
Practice Address - Country:US
Practice Address - Phone:718-746-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005892-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant