Provider Demographics
NPI:1861169237
Name:ACEVES SANTIAGO, ANTONIO MARTIN
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:MARTIN
Last Name:ACEVES SANTIAGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2271
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93275-2271
Mailing Address - Country:US
Mailing Address - Phone:559-350-0227
Mailing Address - Fax:
Practice Address - Street 1:5300 W TULARE AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-3700
Practice Address - Country:US
Practice Address - Phone:805-351-2787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA143264106H00000X
CA129912101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health