Provider Demographics
NPI:1104329531
Name:DE LOS SANTOS, ADAM WILLIAM
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:WILLIAM
Last Name:DE LOS SANTOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5157
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-5157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 WHISPERING WIND DR STE 110
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-8119
Practice Address - Country:US
Practice Address - Phone:209-832-7756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
CARBT-17-31640106S00000X
CA1-21-51628103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician