Provider Demographics
NPI:1447974670
Name:SANTOS, DIANA M
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:SANTOS
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 1:10344 FALCON PARC BLVD APT 203
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-5534
Mailing Address - Country:US
Mailing Address - Phone:407-575-0706
Mailing Address - Fax:
Practice Address - Street 1:10344 FALCON PARC BLVD APT 203
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-5534
Practice Address - Country:US
Practice Address - Phone:407-575-0706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-70862106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113567700Medicaid