Provider Demographics
NPI:1598282691
Name:CRUZ SANTIAGO, ANGIE MELISSA
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:MELISSA
Last Name:CRUZ SANTIAGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 NW 17TH ST APT 212
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33313-5345
Mailing Address - Country:US
Mailing Address - Phone:954-225-5983
Mailing Address - Fax:
Practice Address - Street 1:7000 NW 17TH ST
Practice Address - Street 2:APT 212
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33313
Practice Address - Country:US
Practice Address - Phone:954-225-5983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid