Provider Demographics
NPI:1043498207
Name:CRUZ, MARY ANTONIETTE DETUYATU (RPT)
Entity Type:Individual
Prefix:MS
First Name:MARY ANTONIETTE
Middle Name:DETUYATU
Last Name:CRUZ
Suffix:
Gender:F
Credentials:RPT
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Mailing Address - Street 1:14148 MAGNOLIA BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-6413
Mailing Address - Country:US
Mailing Address - Phone:818-784-3838
Mailing Address - Fax:818-784-3803
Practice Address - Street 1:14148 MAGNOLIA BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-6413
Practice Address - Country:US
Practice Address - Phone:818-784-3838
Practice Address - Fax:818-784-3803
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA28208225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist