Provider Demographics
NPI:1083270862
Name:CRUISE-ROSS, RIO
Entity Type:Individual
Prefix:
First Name:RIO
Middle Name:
Last Name:CRUISE-ROSS
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 1:7807 HAMPTON SUMMIT TER
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-1960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7807 HAMPTON SUMMIT TER
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-1960
Practice Address - Country:US
Practice Address - Phone:804-876-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-19-87262106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician