Provider Demographics
NPI:1215340641
Name:CACERES, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:CACERES
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 1:10045 NW 28TH TER
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-1333
Mailing Address - Country:US
Mailing Address - Phone:786-447-2175
Mailing Address - Fax:
Practice Address - Street 1:7875 NW 12TH ST STE 109
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1815
Practice Address - Country:US
Practice Address - Phone:786-269-3502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-40544103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst