Provider Demographics
NPI:1578374237
Name:SANTIAGO, ELIAS IVAN
Entity type:Individual
Prefix:
First Name:ELIAS
Middle Name:IVAN
Last Name: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 1:9201 SLOOP CT APT 4222
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-4727
Mailing Address - Country:US
Mailing Address - Phone:321-350-4832
Mailing Address - Fax:
Practice Address - Street 1:6650 ROWAN RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-2940
Practice Address - Country:US
Practice Address - Phone:727-597-2335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician