Provider Demographics
NPI:1124512421
Name:CRUZ, DONNA GUADALUPE
Entity type:Individual
Prefix:MISS
First Name:DONNA
Middle Name:GUADALUPE
Last Name:CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 CAMINITO SEPTIMO
Mailing Address - Street 2:
Mailing Address - City:CARDIFF
Mailing Address - State:CA
Mailing Address - Zip Code:92007-1001
Mailing Address - Country:US
Mailing Address - Phone:619-781-7636
Mailing Address - Fax:
Practice Address - Street 1:1220 CAMINITO SEPTIMO
Practice Address - Street 2:
Practice Address - City:CARDIFF
Practice Address - State:CA
Practice Address - Zip Code:92007-1001
Practice Address - Country:US
Practice Address - Phone:619-781-7636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA102898875Medicaid