MEDICARE: MR. TEODULO CRUZ BONZON LCSW

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	1041C0700X	Clinical Social Worker	LCS19646	CA

General Provider Information

NPI Number	:	1497039192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TEODULO CRUZ BONZON LCSW

Provider Business Mailing Address
First Line	:	PO BOX 9405
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91226-0405
Country	:	US
Telephone Number	:	818-846-4469
Fax Number	:

Provider Business Practice Location Address
First Line	:	3013 ANNITA DR
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91206-1302
Country	:	US
Telephone Number	:	818-846-4469
Fax Number	:

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

Provider Enumeration Date	:	09/30/2011
Last Update Date	:	12/30/2019

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