Provider Demographics
NPI:1467177352
Name:DE LA CRUZ MARTIN, GABRIELLE CARIDAD
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:CARIDAD
Last Name:DE LA CRUZ MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:CARIDAD
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8180 LIRIOPE LOOP
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33972-7546
Mailing Address - Country:US
Mailing Address - Phone:786-425-1805
Mailing Address - Fax:
Practice Address - Street 1:8180 LIRIOPE LOOP
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33972-7546
Practice Address - Country:US
Practice Address - Phone:786-425-1805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician