Healthcare Provider Details

I. General information

NPI: 1275300121
Provider Name (Legal Business Name): MARISELA CRUZ CASTRO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 12/11/2023
Certification Date: 12/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 JOHN JONES RD
DAVIS CA
95616-9701
US

IV. Provider business mailing address

5551 DANA AVE
STOCKTON CA
95215-5414
US

V. Phone/Fax

Practice location:
  • Phone: 530-758-2060
  • Fax:
Mailing address:
  • Phone: 209-684-3522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: