Provider Demographics
NPI:1902625429
Name:VASALLO CRUZ, KARELYS
Entity type:Individual
Prefix:
First Name:KARELYS
Middle Name:
Last Name:VASALLO 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 1:6551 SW 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-3218
Mailing Address - Country:US
Mailing Address - Phone:786-338-5269
Mailing Address - Fax:
Practice Address - Street 1:6551 SW 65TH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-3218
Practice Address - Country:US
Practice Address - Phone:786-338-5269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-366343106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty