Healthcare Provider Details

I. General information

NPI: 1306580667
Provider Name (Legal Business Name): JANISHA RYANN CRUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date: 06/01/2022
Reactivation Date: 01/17/2025

III. Provider practice location address

601 S RANCHO DR STE A10
LAS VEGAS NV
89106-4898
US

IV. Provider business mailing address

6720 SURFBIRD ST
NORTH LAS VEGAS NV
89084-2255
US

V. Phone/Fax

Practice location:
  • Phone: 702-437-4673
  • Fax: 702-438-4673
Mailing address:
  • Phone: 725-259-2695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10201-M
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: