Healthcare Provider Details

I. General information

NPI: 1831920537
Provider Name (Legal Business Name): ANGELICA SANTOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2024
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 PARK PLACE BLVD STE C1
KISSIMMEE FL
34741-2358
US

IV. Provider business mailing address

324 DORSETT AVE
LAKE WALES FL
33853-3623
US

V. Phone/Fax

Practice location:
  • Phone: 407-385-0728
  • Fax:
Mailing address:
  • Phone: 860-335-4102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-367342
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: