Provider Demographics
NPI:1730052416
Name:DE LA CRUZ, ELLY
Entity type:Individual
Prefix:
First Name:ELLY
Middle Name:
Last Name:DE LA 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 1:15127 PERDIDO DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-5219
Mailing Address - Country:US
Mailing Address - Phone:407-432-6158
Mailing Address - Fax:
Practice Address - Street 1:15127 PERDIDO DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-5219
Practice Address - Country:US
Practice Address - Phone:407-432-6158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-27
Last Update Date:2025-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty