Provider Demographics
NPI:1720829419
Name:SANTOS, JUSTINA ANNETTE (SUDRC#18331)
Entity type:Individual
Prefix:
First Name:JUSTINA
Middle Name:ANNETTE
Last Name:SANTOS
Suffix:
Gender:F
Credentials:SUDRC#18331
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 W 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-1405
Mailing Address - Country:US
Mailing Address - Phone:213-741-3756
Mailing Address - Fax:
Practice Address - Street 1:145 W 22ND ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-1405
Practice Address - Country:US
Practice Address - Phone:213-741-3756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18331101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)