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: N

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 W LAKE MARY BLVD STE 300
LAKE MARY FL
32746-3499
US

IV. Provider business mailing address

PO BOX 844926
DALLAS TX
75284-4926
US

V. Phone/Fax

Practice location:
  • Phone: 407-423-7149
  • Fax: 407-422-0470
Mailing address:
  • Phone: 407-423-7149
  • Fax: 407-422-0470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH28186
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: