Provider Demographics
NPI:1316512460
Name:SANTIAGO GONZALEZ, CORALYS NICOLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:CORALYS
Middle Name:NICOLE
Last Name:SANTIAGO GONZALEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 RITTENHOUSE TER
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01108-2234
Mailing Address - Country:US
Mailing Address - Phone:787-404-7187
Mailing Address - Fax:
Practice Address - Street 1:80 STATE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2010
Practice Address - Country:US
Practice Address - Phone:413-218-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist