Basic Information
| Provider Information | |||||||||
| NPI: | 1720210669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE LA CRUZ | ||||||||
| FirstName: | CLARA | ||||||||
| MiddleName: | YESENIA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DE JESUS | ||||||||
| OtherFirstName: | CLARA | ||||||||
| OtherMiddleName: | YESENIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | B.A. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1401 S FEDERAL HWY. | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333342619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547288080 | ||||||||
| FaxNumber: | 9547791957 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 S FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547281083 | ||||||||
| FaxNumber: | 9547792316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.