Healthcare Provider Details

I. General information

NPI: 1710570189
Provider Name (Legal Business Name): LAISA MICHELLE CRUZ SANTIAGO MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 US HIGHWAY 27
CLERMONT FL
34714-7520
US

IV. Provider business mailing address

5932 MAUSSER DR. APT D2
ORLANDO FL
32822
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-0573
  • Fax:
Mailing address:
  • Phone: 787-237-0491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: