Provider Demographics
NPI:1285079228
Name:DE LA CRUZ, TERESITA
Entity type:Individual
Prefix:
First Name:TERESITA
Middle Name:
Last Name:DE LA 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 1:7301 BROADWAY EXT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-9045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7301 BROADWAY EXT
Practice Address - Street 2:SUITE 101
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-9045
Practice Address - Country:US
Practice Address - Phone:405-767-1126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX25294202Medicaid