Healthcare Provider Details

I. General information

NPI: 1871838979
Provider Name (Legal Business Name): AIDA IRIS SANTANA MA,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2012
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7424 BOB O LINK WAY
PORT ST LUCIE FL
34986-3340
US

IV. Provider business mailing address

7424 BOB O LINK WAY
PORT ST LUCIE FL
34986-3340
US

V. Phone/Fax

Practice location:
  • Phone: 772-475-5856
  • Fax:
Mailing address:
  • Phone: 772-475-5856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: