Healthcare Provider Details

I. General information

NPI: 1477221760
Provider Name (Legal Business Name): STEPHANIE MARITZA SANTIAGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2021
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N EL CENTRO AVE
LOS ANGELES CA
90038-3805
US

IV. Provider business mailing address

4456 S CENTINELA AVE APT 13
LOS ANGELES CA
90066-6258
US

V. Phone/Fax

Practice location:
  • Phone: 323-983-1487
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW123030
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: