Provider Demographics
NPI:1770177206
Name:SANTIAGO, MARIAN
Entity type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 CALLE MODESTA APT 1904
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00924-4559
Mailing Address - Country:US
Mailing Address - Phone:787-645-6005
Mailing Address - Fax:
Practice Address - Street 1:61 CALLE SAN PATRICIO
Practice Address - Street 2:
Practice Address - City:LOIZA
Practice Address - State:PR
Practice Address - Zip Code:00772-1750
Practice Address - Country:US
Practice Address - Phone:787-310-4397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6908103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist