=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003011263
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLIOT JOSEPH CRUZ LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2007
-----------------------------------------------------
Last Update Date | 06/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4242 MEDICAL DR 7100
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-5640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-216-2739
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3551 ROGER BROOKE DR
-----------------------------------------------------
City | FORT SAM HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78234-4504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-539-9582
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 32873
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------