Healthcare Provider Details

I. General information

NPI: 1083015226
Provider Name (Legal Business Name): MRS. SANDRA DEE CRUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 W. HWY 6
VALPARAISO IN
46368-5885
US

IV. Provider business mailing address

5663 KINGMAN AVE
PORTAGE IN
46368-1521
US

V. Phone/Fax

Practice location:
  • Phone: 219-764-4888
  • Fax: 219-764-7676
Mailing address:
  • Phone: 219-730-6777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: