Provider Demographics
NPI:1598215386
Name:CRUZ, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
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 1:23 ELMWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:CT
Mailing Address - Zip Code:06413-1508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23 ELMWOOD WAY
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:CT
Practice Address - Zip Code:06413-1508
Practice Address - Country:US
Practice Address - Phone:203-339-1191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00609324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility