Healthcare Provider Details

I. General information

NPI: 1649691270
Provider Name (Legal Business Name): ANGELICA SANTIAGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2013
Last Update Date: 12/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 GARDEN PLZ
ORLANDO FL
32803-4212
US

IV. Provider business mailing address

718 GARDEN PLZ
ORLANDO FL
32803-4212
US

V. Phone/Fax

Practice location:
  • Phone: 407-894-8894
  • Fax: 407-894-8893
Mailing address:
  • Phone: 407-894-8894
  • Fax: 407-894-8893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH11866
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: