Basic Information
| Provider Information | |||||||||
| NPI: | 1306354501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUZ | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53 JOHNSON MESA | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875084828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055010370 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2504 CAMINO ENTRADA | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875074851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054715006 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2018 | ||||||||
| LastUpdateDate: | 01/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.