Provider Demographics
NPI:1831967611
Name:MORENO DE LA CRUZ, ELLIS
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:
Last Name:MORENO DE LA CRUZ
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 1:6726 SW 130TH PL APT 1401
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-5619
Mailing Address - Country:US
Mailing Address - Phone:305-496-8044
Mailing Address - Fax:
Practice Address - Street 1:6726 SW 130TH PL APT 1401
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-5619
Practice Address - Country:US
Practice Address - Phone:305-496-8044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-312612106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty