Provider Demographics
NPI:1790362663
Name:SANTIAGO, STACEY J
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:J
Last Name:SANTIAGO
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 1:781 E COTATI AVE APT C2
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-4030
Mailing Address - Country:US
Mailing Address - Phone:072-174-8547
Mailing Address - Fax:
Practice Address - Street 1:1800 HWY 116 N
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-2607
Practice Address - Country:US
Practice Address - Phone:707-634-9070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician