Basic Information
Provider Information | |||||||||
NPI: | 1922768399 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANTIAGO RODRIGUEZ | ||||||||
FirstName: | EDWIN | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MPSY | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | COND. LOMA ALTA VILLAGE, APT. 3702 | ||||||||
Address2: | CAROLINA, P.R. 00987 | ||||||||
City: | CAROLINA | ||||||||
State: | PR | ||||||||
PostalCode: | 00987 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7873784506 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 431 AVE. HOSTOS | ||||||||
Address2: | SAN JUAN P.R. 00918 | ||||||||
City: | SAN JUAN | ||||||||
State: | PR | ||||||||
PostalCode: | 00918 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7877040705 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2021 | ||||||||
LastUpdateDate: | 12/27/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 7077 | PR | Y |   | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.