Healthcare Provider Details

I. General information

NPI: 1497231021
Provider Name (Legal Business Name): BLANCA NYDIA CRUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 FORWARD DR
MADISON WI
53711-2443
US

IV. Provider business mailing address

815 FORWARD DR
MADISON WI
53711-2443
US

V. Phone/Fax

Practice location:
  • Phone: 608-268-6530
  • Fax: 608-709-1744
Mailing address:
  • Phone: 608-268-6530
  • Fax: 608-709-1744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12521-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19827-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: