Healthcare Provider Details

I. General information

NPI: 1407282387
Provider Name (Legal Business Name): JUAN CARLOS SANTANA MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2013
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1985 MAIN ST STE E
SPRINGFIELD MA
01103-1016
US

IV. Provider business mailing address

1985 MAIN ST STE E
SPRINGFIELD MA
01103-1016
US

V. Phone/Fax

Practice location:
  • Phone: 413-736-1458
  • Fax: 413-788-0626
Mailing address:
  • Phone: 413-736-1458
  • Fax: 413-788-0626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.161589
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: