Healthcare Provider Details

I. General information

NPI: 1801015383
Provider Name (Legal Business Name): ANGELICA CRISTINA CRUZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 12/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 W STANDLEY ST
UKIAH CA
95482-4348
US

IV. Provider business mailing address

6 TARMAN DR
CLOVERDALE CA
95425-3932
US

V. Phone/Fax

Practice location:
  • Phone: 707-621-1538
  • Fax:
Mailing address:
  • Phone: 707-894-4229
  • Fax: 707-894-2954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW26456
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26456
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: