Provider Demographics
NPI:1063920809
Name:SANTIAGO CARMONA, MANUEL A (MA)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:A
Last Name:SANTIAGO CARMONA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 ISSAQUAH PINE LAKE RD SE APT B14
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98075-6280
Mailing Address - Country:US
Mailing Address - Phone:787-306-8193
Mailing Address - Fax:
Practice Address - Street 1:4425 ISSAQUAH PINE LAKE RD SE APT B14
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98075-6280
Practice Address - Country:US
Practice Address - Phone:787-306-8193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-15
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst