Provider Demographics
NPI:1043836323
Name:DE LA RUA, YEISEL
Entity Type:Individual
Prefix:
First Name:YEISEL
Middle Name:
Last Name:DE LA RUA
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 1:15184 88TH PL N
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-4338
Mailing Address - Country:US
Mailing Address - Phone:561-267-6758
Mailing Address - Fax:
Practice Address - Street 1:15184 88TH PL N
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-4338
Practice Address - Country:US
Practice Address - Phone:561-267-6758
Practice Address - Fax:561-594-1835
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-254029106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst