Healthcare Provider Details

I. General information

NPI: 1114137684
Provider Name (Legal Business Name): ERNESTO SANTISTEVAN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 2ND ST STE 44
SANTA FE NM
87505-3499
US

IV. Provider business mailing address

1000 CORDOVA PL #548
SANTA FE NM
87505-1725
US

V. Phone/Fax

Practice location:
  • Phone: 505-577-2607
  • Fax: 505-982-1096
Mailing address:
  • Phone: 505-577-2607
  • Fax: 505-982-1096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number688
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: