Provider Demographics
NPI:1053584359
Name:SANTIAGO-BURGOS, MAYRA (LCSW)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:SANTIAGO-BURGOS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 KING ST
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-1014
Mailing Address - Country:US
Mailing Address - Phone:860-297-0938
Mailing Address - Fax:860-297-6338
Practice Address - Street 1:500 VINE ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1639
Practice Address - Country:US
Practice Address - Phone:860-297-0938
Practice Address - Fax:860-293-6338
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0046891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical