Provider Demographics
NPI:1700642642
Name:CRUZ BASALLO, ADIANES DE LOS ANGELES (RBT)
Entity Type:Individual
Prefix:
First Name:ADIANES
Middle Name:DE LOS ANGELES
Last Name:CRUZ BASALLO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7585 SW 152ND AVE APT G209
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-3260
Mailing Address - Country:US
Mailing Address - Phone:786-836-8270
Mailing Address - Fax:786-391-0567
Practice Address - Street 1:18646 NW 53RD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-5307
Practice Address - Country:US
Practice Address - Phone:786-458-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-330187106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician