Healthcare Provider Details

I. General information

NPI: 1629205463
Provider Name (Legal Business Name): SANTIAGO RIVERA-SANTOS PH. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2009
Last Update Date: 06/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 CALLE TETUAN APT. 9 OLD SJ
SAN JUAN PR
00901-1959
US

IV. Provider business mailing address

255 CALLE TETUAN APT. 9 OLD SJ
SAN JUAN PR
00901-1959
US

V. Phone/Fax

Practice location:
  • Phone: 939-628-9484
  • Fax:
Mailing address:
  • Phone: 939-628-9484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number3398
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number3398
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number3398
License Number StatePR
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3398
License Number StatePR
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number3398
License Number StatePR
# 6
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number3398
License Number StatePR
# 7
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number3398
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: