Provider Demographics
NPI:1104264498
Name:SANTIAGO, TINA MARIE (MA, LMFTA)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:MA, LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6203 JAMESTOWN LN SE
Mailing Address - Street 2:APT D103
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-4817
Practice Address - Country:US
Practice Address - Phone:360-330-7181
Practice Address - Fax:360-748-0627
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMFTA.MG.60224659106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist