Healthcare Provider Details

I. General information

NPI: 1528844313
Provider Name (Legal Business Name): MAYIEVIN DE LA CRUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2023
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 WARREN ST STE 23
HACKENSACK NJ
07601-5436
US

IV. Provider business mailing address

129 HOWLAND AVE APT 2B
RIVER EDGE NJ
07661-1742
US

V. Phone/Fax

Practice location:
  • Phone: 201-205-1131
  • Fax:
Mailing address:
  • Phone: 917-622-0514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00741500
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: