Basic Information
| Provider Information | |||||||||
| NPI: | 1417301532 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTOS | ||||||||
| FirstName: | EDMUND | ||||||||
| MiddleName: | ROBERTO | ||||||||
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| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 731 MALL RING CIR | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890146683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025476971 | ||||||||
| FaxNumber: | 7025476948 | ||||||||
| Practice Location | |||||||||
| Address1: | 731 MALL RING CIR | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890146683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025476971 | ||||||||
| FaxNumber: | 7025476948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2016 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | RBT-15-02170 | NV | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106E00000X | 0-19-9614 | NV | Y |
ID Information
| ID | Type | State | Issuer | Description | 0-19-9614 | 01 | NV | BACB | OTHER |