MEDICARE: DR. BERTHA LUCIA CRUZ PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	015979	NY
2	103T00000X	Psychologist	002903	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	002903	OTHER	CT	PSYCHOLOGIST
2	015979	OTHER	NY	PSYCHOLOGIST LICENSE

General Provider Information

NPI Number	:	1245512151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BERTHA LUCIA CRUZ PSY.D.

Provider Business Mailing Address
First Line	:	72 HARBOR DR
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06902-7455
Country	:	US
Telephone Number	:	203-550-6749
Fax Number	:	203-359-6559

Provider Business Practice Location Address
First Line	:	18 CENTRAL AVE
Second Line	:
City	:	PORT CHESTER
State	:	NY
Zip	:	10573-5004
Country	:	US
Telephone Number	:	914-934-8045
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2011
Last Update Date	:	09/16/2011

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