Healthcare Provider Details

I. General information

NPI: 1205116381
Provider Name (Legal Business Name): CHAGO V MATOS SANTIAGO PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ITURREGUI PLAZA 65 INFANTERIA SUITE 217-B
SAN JUAN PR
00924
US

IV. Provider business mailing address

ITURREGUI PLAZA 65 INFANTERIA SUITE 217-B
SAN JUAN PR
00924
US

V. Phone/Fax

Practice location:
  • Phone: 787-701-2626
  • Fax: 787-768-8094
Mailing address:
  • Phone: 787-701-2626
  • Fax: 787-768-8094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4014
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: