=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083410112
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LLELIDZA BRUNILDA SANTIAGO MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2025
-----------------------------------------------------
Last Update Date | 02/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | MANSIONES EN PASEO DE LOS REYES CALLE REINA ALEXANDRA 49
-----------------------------------------------------
City | JUANA DIAZ
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-381-5794
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2446
-----------------------------------------------------
City | COAMO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00769-4446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-381-5794
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 14172
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------