Basic Information
| Provider Information | |||||||||
| NPI: | 1811373368 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JUAREZ | ||||||||
| FirstName: | SANTOS | ||||||||
| MiddleName: | JUNIOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 919 | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928360919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146809000 | ||||||||
| FaxNumber: | 7146808233 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 E CHAPMAN AVE STE 203 | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928313846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146809000 | ||||||||
| FaxNumber: | 7146808233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2015 | ||||||||
| LastUpdateDate: | 12/02/2019 | ||||||||
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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 | 101Y00000X | ENROLLED IN TRAINING | N | Behavioral Health & Social Service Providers | Counselor | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.