1912497769 NPI number — MR. CHEMAL YSIDRO CRUZ M.A.,LMHC, NCC, CCTP

Table of content: MR. CHEMAL YSIDRO CRUZ M.A.,LMHC, NCC, CCTP (NPI 1912497769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912497769 NPI number — MR. CHEMAL YSIDRO CRUZ M.A.,LMHC, NCC, CCTP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRUZ
Provider First Name:
CHEMAL
Provider Middle Name:
YSIDRO
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.A.,LMHC, NCC, CCTP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912497769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10810 BOYETTE ROAD
Provider Second Line Business Mailing Address:
#2563
Provider Business Mailing Address City Name:
RIVERVIEW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33569-8000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-803-5950
Provider Business Mailing Address Fax Number:
833-233-3084

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10810 BOYETTE ROAD
Provider Second Line Business Practice Location Address:
#2563
Provider Business Practice Location Address City Name:
RIVERVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33569-8000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-803-5950
Provider Business Practice Location Address Fax Number:
833-233-3084
Provider Enumeration Date:
05/17/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: MH19886 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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