Basic Information
Provider Information
NPI: 1003140252
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CRUZ
FirstName: ELIZABETH
MiddleName:  
NamePrefix: MISS
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1533 EUCLID STREET
Address2:  
City: SANTA MONICA
State: CA
PostalCode: 90404
CountryCode: US
TelephoneNumber: 3104519747
FaxNumber: 3104516106
Practice Location
Address1: 1533 EUCLID STREET
Address2:  
City: SANTA MONICA
State: CA
PostalCode: 90404
CountryCode: US
TelephoneNumber: 3104519747
FaxNumber: 3104516106
Other Information
ProviderEnumerationDate: 09/21/2009
LastUpdateDate: 02/02/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X69997CAY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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