Provider Demographics
NPI:1043642549
Name:ROMAN SANTOS, STELLA G (MS, PHD)
Entity type:Individual
Prefix:DR
First Name:STELLA
Middle Name:G
Last Name:ROMAN SANTOS
Suffix:
Gender:F
Credentials:MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N SEMORAN BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-3562
Mailing Address - Country:US
Mailing Address - Phone:407-823-8421
Mailing Address - Fax:407-823-8195
Practice Address - Street 1:1400 N SEMORAN BLVD STE E
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-3562
Practice Address - Country:US
Practice Address - Phone:407-823-8421
Practice Address - Fax:407-823-8195
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR005167103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110027780BMedicaid
MA04-2103756OtherEIN
MAY10246Medicare UPIN