Provider Demographics
NPI:1558079574
Name:DE LA CRUZ, KEVIN LAZARO
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LAZARO
Last Name:DE LA CRUZ
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 1:3218 W 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5411
Mailing Address - Country:US
Mailing Address - Phone:786-357-6624
Mailing Address - Fax:
Practice Address - Street 1:941 SW 87TH AVE STE A
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-3206
Practice Address - Country:US
Practice Address - Phone:786-953-6418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician