Provider Demographics
NPI:1548926504
Name:CRUZ, JIMMY
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:CRUZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:961 REV JAMES A POLITE AVE APT 512
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-3569
Mailing Address - Country:US
Mailing Address - Phone:347-238-4273
Mailing Address - Fax:
Practice Address - Street 1:961 REV JAMES A POLITE AVE APT 512
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-3569
Practice Address - Country:US
Practice Address - Phone:347-238-4273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1554292212252Y00000X, 106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No252Y00000XAgenciesEarly Intervention Provider Agency