Basic Information
| Provider Information | |||||||||
| NPI: | 1871770800 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTIAGO | ||||||||
| FirstName: | VIVIAN | ||||||||
| MiddleName: | VANESSA | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8 GREAT COVE LN | ||||||||
| Address2: | |||||||||
| City: | ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117514505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164855710 | ||||||||
| FaxNumber: | 5164854225 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 FULTON AVE | ||||||||
| Address2: | F.E.G.S. 3RD FLOOR | ||||||||
| City: | HEMPSTEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115503718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164855710 | ||||||||
| FaxNumber: | 5164854225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 04/04/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 064342-1 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 080554-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.