MEDICARE: ALYSSIA CRUZ LCSW

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	101Y00000X	Counselor	83876	CA
2	1041C0700X	Clinical Social Worker	83876	CA
3	1041C0700X	Clinical Social Worker	97269	CA

General Provider Information

NPI Number	:	1275066193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSIA CRUZ LCSW

Provider Business Mailing Address
First Line	:	4231 BALBOA AVE # 3010
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-5504
Country	:	US
Telephone Number	:	619-630-9312
Fax Number	:

Provider Business Practice Location Address
First Line	:	2245 CHALLENGER WAY
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95407-5418
Country	:	US
Telephone Number	:	707-565-4431
Fax Number	:

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

Provider Enumeration Date	:	04/07/2017
Last Update Date	:	08/31/2021

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