Provider Demographics
NPI:1912497769
Name:CRUZ, CHEMAL YSIDRO (MA,LMHC, NCC, CCTP)
Entity Type:Individual
Prefix:MR
First Name:CHEMAL
Middle Name:YSIDRO
Last Name:CRUZ
Suffix:
Gender:M
Credentials:MA,LMHC, NCC, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10810 BOYETTE ROAD
Mailing Address - Street 2:#2563
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-8000
Mailing Address - Country:US
Mailing Address - Phone:813-803-5950
Mailing Address - Fax:833-233-3084
Practice Address - Street 1:10810 BOYETTE ROAD
Practice Address - Street 2:#2563
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-8000
Practice Address - Country:US
Practice Address - Phone:813-803-5950
Practice Address - Fax:833-233-3084
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-17
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMH19886101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health