Healthcare Provider Details

I. General information

NPI: 1013614122
Provider Name (Legal Business Name): KEVIN SANTOS PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 S FAIRFAX AVE STE 200
LOS ANGELES CA
90036-2186
US

IV. Provider business mailing address

169 MADISON AVE STE 15824
NEW YORK NY
10016-5101
US

V. Phone/Fax

Practice location:
  • Phone: 909-679-3482
  • Fax:
Mailing address:
  • Phone: 909-679-3482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95021879
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: