Provider Demographics
NPI:1306984257
Name:SANTOS, JOANNA
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:SANTOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 W ERIE ST
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:AZ
Mailing Address - Zip Code:86025-2430
Mailing Address - Country:US
Mailing Address - Phone:928-313-3598
Mailing Address - Fax:
Practice Address - Street 1:1537 PORTER CANYON RD
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025-3303
Practice Address - Country:US
Practice Address - Phone:928-313-3598
Practice Address - Fax:602-455-4624
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
385HR2055X
AZ11383253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child