Healthcare Provider Details

I. General information

NPI: 1871614420
Provider Name (Legal Business Name): IBIS DANITZIA NUNEZ-SANTIAGO PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 BOONE RIDGE DR STE 201
JOHNSON CITY TN
37615-4998
US

IV. Provider business mailing address

PO BOX 2034
SYLVA NC
28779-2034
US

V. Phone/Fax

Practice location:
  • Phone: 423-282-1480
  • Fax: 423-928-1353
Mailing address:
  • Phone: 828-586-8160
  • Fax: 828-586-8209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4066
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1174
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3389
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: