Provider Demographics
NPI:1881080604
Name:SANTILLAN, MANUEL URIEL JR
Entity type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:URIEL
Last Name:SANTILLAN
Suffix:JR
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 1:1237 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-6205
Mailing Address - Country:US
Mailing Address - Phone:831-320-0521
Mailing Address - Fax:
Practice Address - Street 1:1133 COLOMA WAY STE C
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4480
Practice Address - Country:US
Practice Address - Phone:916-774-6647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC056610518101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)