Provider Demographics
NPI:1487296851
Name:SANTIAGO, ROMEL POWELL (LCSW)
Entity type:Individual
Prefix:MR
First Name:ROMEL
Middle Name:POWELL
Last Name:SANTIAGO
Suffix:
Gender:M
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:PO BOX 263244
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33685-3244
Mailing Address - Country:US
Mailing Address - Phone:813-461-3098
Mailing Address - Fax:813-475-4431
Practice Address - Street 1:1210 MILLENNIUM PKWY STE 1030
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4858
Practice Address - Country:US
Practice Address - Phone:813-461-3098
Practice Address - Fax:813-475-4431
Is Sole Proprietor?:No
Enumeration Date:2019-10-17
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW167531041C0700X
MD235651041C0700X
FL167531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107156800Medicaid