Provider Demographics
NPI:1538610324
Name:SANTISTEVAN, KC (MSW, PCSW)
Entity type:Individual
Prefix:
First Name:KC
Middle Name:
Last Name:SANTISTEVAN
Suffix:
Gender:M
Credentials:MSW, PCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3672 S 100 W
Mailing Address - Street 2:
Mailing Address - City:NIBLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84321-7983
Mailing Address - Country:US
Mailing Address - Phone:435-764-5237
Mailing Address - Fax:
Practice Address - Street 1:2001 DEWAR DR
Practice Address - Street 2:#270
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5773
Practice Address - Country:US
Practice Address - Phone:435-764-5237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPCSW-6451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical