Provider Demographics
NPI:1043779341
Name:CRUSETA, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:CRUSETA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-3449
Mailing Address - Country:US
Mailing Address - Phone:978-467-3183
Mailing Address - Fax:
Practice Address - Street 1:96 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-3449
Practice Address - Country:US
Practice Address - Phone:978-467-3183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-16
Last Update Date:2019-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst