Provider Demographics
NPI:1316724719
Name:BUSOT CRUZ, ELLENS (BCABA)
Entity type:Individual
Prefix:
First Name:ELLENS
Middle Name:
Last Name:BUSOT CRUZ
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14194 SW 148TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-5668
Mailing Address - Country:US
Mailing Address - Phone:786-378-3254
Mailing Address - Fax:
Practice Address - Street 1:14194 SW 148TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-5668
Practice Address - Country:US
Practice Address - Phone:786-378-3254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBCABA-0-2314639106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty