Healthcare Provider Details

I. General information

NPI: 1255184065
Provider Name (Legal Business Name): GABRIEL ANTONIO SANTIAGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6953 UNIVERSITY BLVD
WINTER PARK FL
32792-6710
US

IV. Provider business mailing address

4032 BARNSLEY DR
ORLANDO FL
32812-8118
US

V. Phone/Fax

Practice location:
  • Phone: 407-543-8356
  • Fax: 407-264-6443
Mailing address:
  • Phone: 863-558-6902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-338807
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: