Healthcare Provider Details

I. General information

NPI: 1083045538
Provider Name (Legal Business Name): MR. ROBERT SANTOS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2013
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 NORRIS RD
SAGAMORE BEACH MA
02562-2516
US

IV. Provider business mailing address

81 NORRIS RD
SAGAMORE BEACH MA
02562-2516
US

V. Phone/Fax

Practice location:
  • Phone: 781-534-3637
  • Fax:
Mailing address:
  • Phone: 781-534-3637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: