Provider Demographics
NPI:1043750045
Name:DE LA CRUZ, KARELY
Entity Type:Individual
Prefix:
First Name:KARELY
Middle Name:
Last Name:DE LA 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 1:405 W MANCHESTER BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1196
Mailing Address - Country:US
Mailing Address - Phone:310-672-3820
Mailing Address - Fax:
Practice Address - Street 1:405 W MANCHESTER BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1196
Practice Address - Country:US
Practice Address - Phone:310-672-3820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)