Provider Demographics
NPI:1982340618
Name:DESANTANA, NATHANAEL (MS)
Entity Type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:
Last Name:DESANTANA
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 SOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2816
Mailing Address - Country:US
Mailing Address - Phone:215-908-8973
Mailing Address - Fax:
Practice Address - Street 1:987 OLD EAGLE RD STE 719
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-1708
Practice Address - Country:US
Practice Address - Phone:610-999-6414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health