Provider Demographics
NPI:1487244521
Name:SANTOS, KAHLEA LAURENA OLVIDADO
Entity type:Individual
Prefix:
First Name:KAHLEA
Middle Name:LAURENA OLVIDADO
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 1:701 E FOOTHILL BLVD UNIT 8274
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-2606
Mailing Address - Country:US
Mailing Address - Phone:650-267-3092
Mailing Address - Fax:
Practice Address - Street 1:677 CLIFFSIDE DR
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2957
Practice Address - Country:US
Practice Address - Phone:626-345-6455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY5336175106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician