Provider Demographics
NPI:1588246359
Name:CRUZ, KIMBERLY (RBT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:VAN EMMERIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RBT
Mailing Address - Street 1:1210 SE 46TH LN STE 1
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-8601
Mailing Address - Country:US
Mailing Address - Phone:239-268-8707
Mailing Address - Fax:
Practice Address - Street 1:1210 SE 46TH LN STE 1
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-8601
Practice Address - Country:US
Practice Address - Phone:239-268-8707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-158767106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109788500Medicaid