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: 06/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 MAIN ST
SPRINGFIELD MA
01104-3301
US

IV. Provider business mailing address

147 NORMAN ST
WEST SPRINGFIELD MA
01089-5003
US

V. Phone/Fax

Practice location:
  • Phone: 413-736-0395
  • Fax: 413-734-1651
Mailing address:
  • Phone: 413-736-8329
  • Fax: 413-732-5362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3680
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3680
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: