Healthcare Provider Details

I. General information

NPI: 1104119064
Provider Name (Legal Business Name): MICHELLE SANTIAGO LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 05/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1857 WOODPOINTE DR
WINTER HAVEN FL
33884-2876
US

IV. Provider business mailing address

1857 WOODPOINTE DR
WINTER HAVEN FL
33884-2876
US

V. Phone/Fax

Practice location:
  • Phone: 863-325-6201
  • Fax:
Mailing address:
  • Phone: 863-325-6201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA21876
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: