Healthcare Provider Details

I. General information

NPI: 1568763712
Provider Name (Legal Business Name): CARLOS R CRUZ LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

553 58TH ST 2I
BROOKLYN NY
11220-3842
US

IV. Provider business mailing address

553 58TH ST AOARTMENT21
BROOKLYN NY
11220-3842
US

V. Phone/Fax

Practice location:
  • Phone: 347-335-7759
  • Fax: 718-293-3980
Mailing address:
  • Phone: 347-335-7759
  • Fax: 845-255-0236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number017450
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: