Healthcare Provider Details

I. General information

NPI: 1457943656
Provider Name (Legal Business Name): MARISOL CRUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 BEAVER RD
WETHERSFIELD CT
06109-2249
US

IV. Provider business mailing address

61 BEAVER RD
WETHERSFIELD CT
06109-2249
US

V. Phone/Fax

Practice location:
  • Phone: 203-679-9641
  • Fax:
Mailing address:
  • Phone: 203-679-9641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17084
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: