Provider Demographics
NPI:1508610247
Name:CRUZ CARLO, JOSE MANUEL
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MANUEL
Last Name:CRUZ CARLO
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 1:1687 BUCKEYE FALLS WAY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-4347
Mailing Address - Country:US
Mailing Address - Phone:407-445-8915
Mailing Address - Fax:
Practice Address - Street 1:222 BROADWAY UNIT 211
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5760
Practice Address - Country:US
Practice Address - Phone:407-329-3464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8321104100000X
FLCBHCM.0106555-P104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker