1801902036 NPI number — FIORDALISA R. SANTIAGO LCSW-R

Table of content: FIORDALISA R. SANTIAGO LCSW-R (NPI 1801902036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801902036 NPI number — FIORDALISA R. SANTIAGO LCSW-R

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANTIAGO
Provider First Name:
FIORDALISA
Provider Middle Name:
R.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW-R
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RODRIGUEZ
Provider Other First Name:
LISA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801902036
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3485 E TREMONT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10465-2016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-828-1549
Provider Business Mailing Address Fax Number:
718-828-5029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6214 RIVERDALE AVE
Provider Second Line Business Practice Location Address:
STE 2C
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10471-1032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-796-6315
Provider Business Practice Location Address Fax Number:
866-490-9850
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  058978 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: R058978 . This is a "NYS LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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