Provider Demographics
NPI:1770761181
Name:SANTANA, MAYRA EMILIA (CASAC)
Entity type:Individual
Prefix:MS
First Name:MAYRA
Middle Name:EMILIA
Last Name:SANTANA
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-2130
Mailing Address - Country:US
Mailing Address - Phone:631-355-6889
Mailing Address - Fax:
Practice Address - Street 1:2075 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-3238
Practice Address - Country:US
Practice Address - Phone:631-351-7112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18589101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)