Provider Demographics
NPI:1386149953
Name:AVITIA, MARICRUZ (LLPC)
Entity type:Individual
Prefix:
First Name:MARICRUZ
Middle Name:
Last Name:AVITIA
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5096 HARBOR OARK DR.
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-1726
Mailing Address - Country:US
Mailing Address - Phone:248-495-7016
Mailing Address - Fax:
Practice Address - Street 1:5096 HARBOR OARK DR.
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-1726
Practice Address - Country:US
Practice Address - Phone:248-495-7016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803083952104100000X
MI6401010636101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker