Provider Demographics
NPI:1528467941
Name:CRUZ, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:CRUZ
Other - Last Name:WILKEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 28
Mailing Address - Street 2:
Mailing Address - City:MORONI
Mailing Address - State:UT
Mailing Address - Zip Code:84646-0028
Mailing Address - Country:US
Mailing Address - Phone:435-851-9664
Mailing Address - Fax:435-436-5322
Practice Address - Street 1:4800 E 17160 N
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646
Practice Address - Country:US
Practice Address - Phone:435-851-9664
Practice Address - Fax:435-436-5322
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor