Basic Information
| Provider Information | |||||||||
| NPI: | 1487913703 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DE SANTIAGO | ||||||||
| FirstName: | VANESSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5520 DENNIS CAVIN LN | ||||||||
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| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799343281 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11351 JAMES WATT DR STE A | ||||||||
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| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9158496602 | ||||||||
| FaxNumber: | 9155851889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2012 | ||||||||
| LastUpdateDate: | 07/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 114769 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 207164901 | 05 | TX | MEDICAID | 149984001 | 05 | TX | MEDICAID |