Provider Demographics
NPI:1104348051
Name:DE LA CRUZ, VIVIANET (MS ED)
Entity type:Individual
Prefix:
First Name:VIVIANET
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 NAGLE AVE APT 7K
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-6085
Mailing Address - Country:US
Mailing Address - Phone:646-591-9458
Mailing Address - Fax:
Practice Address - Street 1:1909 LONGFELLOW AVENUE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460
Practice Address - Country:US
Practice Address - Phone:347-497-3998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY174400000XOtherTEACHER