Provider Demographics
NPI:1588486187
Name:CRUZ, LISANDRA
Entity type:Individual
Prefix:
First Name:LISANDRA
Middle Name:
Last Name:CRUZ
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 1:2950 S BERMUDA AVE
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-5962
Mailing Address - Country:US
Mailing Address - Phone:305-796-2300
Mailing Address - Fax:
Practice Address - Street 1:2950 S BERMUDA AVE
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-5962
Practice Address - Country:US
Practice Address - Phone:305-796-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-26
Last Update Date:2024-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLC621520865010106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty