Provider Demographics
NPI:1144479718
Name:SANTOS, SERGIO XAVIER (BA, LISAC)
Entity type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:XAVIER
Last Name:SANTOS
Suffix:
Gender:M
Credentials:BA, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 N 19TH AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2451
Mailing Address - Country:US
Mailing Address - Phone:602-589-0500
Mailing Address - Fax:602-314-4552
Practice Address - Street 1:5501 N 19TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015
Practice Address - Country:US
Practice Address - Phone:602-589-0500
Practice Address - Fax:602-314-4552
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-1627101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ600241392OtherMAGELLAN