Provider Demographics
NPI:1053146753
Name:MORENTE SANTIESTEBAN, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MORENTE SANTIESTEBAN
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 1:9468 WINDERMERE LAKE DR APT 201
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-2535
Mailing Address - Country:US
Mailing Address - Phone:813-502-8630
Mailing Address - Fax:
Practice Address - Street 1:504 E BAKER ST STE 1
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-3558
Practice Address - Country:US
Practice Address - Phone:813-704-6297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-04
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24374510106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician