Provider Demographics
NPI:1629635073
Name:DE LA CRUZ, JOSE MIGUEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:MIGUEL
Last Name:DE LA CRUZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11901 LANDING POINT LOOP
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-5904
Mailing Address - Country:US
Mailing Address - Phone:407-801-2191
Mailing Address - Fax:
Practice Address - Street 1:6900 TAVISTOCK LAKES BLVD STE 400
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7593
Practice Address - Country:US
Practice Address - Phone:407-801-2191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL149501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty