Provider Demographics
NPI:1760677884
Name:DE LA CRUZ, BERENICE (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:BERENICE
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11712 DUNBLANE WAY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78754-5870
Mailing Address - Country:US
Mailing Address - Phone:512-299-4456
Mailing Address - Fax:512-472-5787
Practice Address - Street 1:11712 DUNBLANE WAY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-5870
Practice Address - Country:US
Practice Address - Phone:512-299-4456
Practice Address - Fax:512-472-5787
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1062804101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
260560776OtherFEDERAL ID #