Provider Demographics
NPI:1871199034
Name:GONZALES, SANTINO JAMES JAMES DOMINQUE
Entity type:Individual
Prefix:
First Name:SANTINO JAMES
Middle Name:JAMES DOMINQUE
Last Name:GONZALES
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 1:3359 ANGEL DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601-7202
Mailing Address - Country:US
Mailing Address - Phone:989-780-7186
Mailing Address - Fax:
Practice Address - Street 1:296 BRIDGEPORT VILLAGE SQUARE DRIVE SUITE 2
Practice Address - Street 2:
Practice Address - City:BRIDGPORT
Practice Address - State:MI
Practice Address - Zip Code:48601-7202
Practice Address - Country:US
Practice Address - Phone:989-401-1239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician