Healthcare Provider Details

I. General information

NPI: 1659793388
Provider Name (Legal Business Name): ALFREDO SANTIAGO LGSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N CHARLES ST
BALTIMORE MD
21201-5505
US

IV. Provider business mailing address

1111 N CHARLES ST
BALTIMORE MD
21201-5505
US

V. Phone/Fax

Practice location:
  • Phone: 410-837-2050
  • Fax: 866-629-0091
Mailing address:
  • Phone: 410-837-2050
  • Fax: 866-629-0091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16527
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: