Healthcare Provider Details

I. General information

NPI: 1871770800
Provider Name (Legal Business Name): VIVIAN VANESSA SANTIAGO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 FULTON AVE F.E.G.S. 3RD FLOOR
HEMPSTEAD NY
11550-3718
US

IV. Provider business mailing address

8 GREAT COVE LN
ISLIP NY
11751-4505
US

V. Phone/Fax

Practice location:
  • Phone: 516-485-5710
  • Fax: 516-485-4225
Mailing address:
  • Phone: 516-485-5710
  • Fax: 516-485-4225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number064342-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number080554-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: