Provider Demographics
NPI:1164987202
Name:DE LA CRUZ, JOSE SR (ABA)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:
Last Name:DE LA CRUZ
Suffix:SR
Gender:M
Credentials:ABA
Other - Prefix:MR
Other - First Name:JOSE
Other - Middle Name:DE LA
Other - Last Name:CRUZ
Other - Suffix:SR
Other - Last Name Type:Other Name
Other - Credentials:ABA
Mailing Address - Street 1:61 FENNER AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-1049
Mailing Address - Country:US
Mailing Address - Phone:973-510-4089
Mailing Address - Fax:
Practice Address - Street 1:61 FENNER AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-1049
Practice Address - Country:US
Practice Address - Phone:973-510-4089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-03
Last Update Date:2019-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0450343237103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty