Provider Demographics
NPI:1003656455
Name:JIMENEZ-CRUZ, IVELISSI (RBT-24-329505)
Entity type:Individual
Prefix:
First Name:IVELISSI
Middle Name:
Last Name:JIMENEZ-CRUZ
Suffix:
Gender:F
Credentials:RBT-24-329505
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10839 SAKONNET RIVER DR APT 203
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-2899
Mailing Address - Country:US
Mailing Address - Phone:813-415-7581
Mailing Address - Fax:
Practice Address - Street 1:3104 W WATERS AVE STE 204
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2877
Practice Address - Country:US
Practice Address - Phone:813-265-4439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-31
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-329505106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician