Provider Demographics
NPI:1659025476
Name:CRUCES, MIGUEL MARCELO
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:MARCELO
Last Name:CRUCES
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 1:20200 SW 320TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-5103
Mailing Address - Country:US
Mailing Address - Phone:305-450-5976
Mailing Address - Fax:
Practice Address - Street 1:20200 SW 320TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-5103
Practice Address - Country:US
Practice Address - Phone:305-450-5976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21-196957106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician