MEDICARE: NICOLE CRUZ M.S., B.C.B.A.,

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	103K00000X	Behavior Analyst	1-13-13466	CA

General Provider Information

NPI Number	:	1770905499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE CRUZ M.S., B.C.B.A.,

Provider Business Mailing Address
First Line	:	3244 PROSPECT PARK DR
Second Line	:
City	:	RANCHO CORDOVA
State	:	CA
Zip	:	95670-6244
Country	:	US
Telephone Number	:	916-220-2921
Fax Number	:

Provider Business Practice Location Address
First Line	:	3244 PROSPECT PARK DR
Second Line	:
City	:	RANCHO CORDOVA
State	:	CA
Zip	:	95670-6244
Country	:	US
Telephone Number	:	916-220-2921
Fax Number	:

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

Provider Enumeration Date	:	01/15/2014
Last Update Date	:	05/23/2014

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