Provider Demographics
NPI:1679346696
Name:SANTA CRUZ BOUS, LILIAN
Entity Type:Individual
Prefix:
First Name:LILIAN
Middle Name:
Last Name:SANTA CRUZ BOUS
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 1:10422 SW 138TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-3163
Mailing Address - Country:US
Mailing Address - Phone:929-605-8291
Mailing Address - Fax:
Practice Address - Street 1:10422 SW 138TH PL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-3163
Practice Address - Country:US
Practice Address - Phone:929-605-8291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty