Provider Demographics
NPI:1124777909
Name:FERNANDEZ DE LA CRUZ, CARMEN J (RBT)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:J
Last Name:FERNANDEZ DE LA CRUZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 NE JUANITA PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-9230
Mailing Address - Country:US
Mailing Address - Phone:704-941-8723
Mailing Address - Fax:
Practice Address - Street 1:1729 NE JUANITA PL
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-9230
Practice Address - Country:US
Practice Address - Phone:704-941-8723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician