Provider Demographics
NPI:1841860194
Name:SANTOS, RYSA SHAVONNE
Entity type:Individual
Prefix:
First Name:RYSA
Middle Name:SHAVONNE
Last Name:SANTOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RYSA
Other - Middle Name:SHAVONNE
Other - Last Name:EDWARDS-WALCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6321 N WASHTENAW AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-1700
Mailing Address - Country:US
Mailing Address - Phone:954-913-9255
Mailing Address - Fax:
Practice Address - Street 1:3046 W ARMITAGE AVE APT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5935
Practice Address - Country:US
Practice Address - Phone:954-913-9255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional