Provider Demographics
NPI:1235738808
Name:CRUZ GORGOY, MARLON ANDRES
Entity Type:Individual
Prefix:
First Name:MARLON
Middle Name:ANDRES
Last Name:CRUZ GORGOY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 TAYLOR ST APT 102
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-4454
Mailing Address - Country:US
Mailing Address - Phone:754-581-0032
Mailing Address - Fax:
Practice Address - Street 1:3 SW 129TH AVE STE 203
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1779
Practice Address - Country:US
Practice Address - Phone:954-589-2539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician