MEDICARE: MR. CHEMAL YSIDRO CRUZ M.A.,LMHC, NCC, CCTP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	101YM0800X	Mental Health Counselor	MH19886	FL

General Provider Information

NPI Number	:	1912497769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHEMAL YSIDRO CRUZ M.A.,LMHC, NCC, CCTP

Provider Business Mailing Address
First Line	:	10810 BOYETTE ROAD
Second Line	:	#2563
City	:	RIVERVIEW
State	:	FL
Zip	:	33569-8000
Country	:	US
Telephone Number	:	813-803-5950
Fax Number	:	833-233-3084

Provider Business Practice Location Address
First Line	:	10810 BOYETTE ROAD
Second Line	:	#2563
City	:	RIVERVIEW
State	:	FL
Zip	:	33569-8000
Country	:	US
Telephone Number	:	813-803-5950
Fax Number	:	833-233-3084

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2018
Last Update Date	:	04/01/2022

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