Provider Demographics
NPI:1306615265
Name:CRUISE, KEITH (PHD, MLS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:CRUISE
Suffix:
Gender:M
Credentials:PHD, MLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 E 30TH ST APT 15N
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6439
Mailing Address - Country:US
Mailing Address - Phone:504-905-5729
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF PSYCHOLOGY
Practice Address - Street 2:441 EAST FORDHAM RD
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458
Practice Address - Country:US
Practice Address - Phone:718-817-3883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016973103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical