Provider Demographics
NPI:1073387593
Name:CRUZ, MERCEDES
Entity Type:Individual
Prefix:
First Name:MERCEDES
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:PO BOX 137051
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76136-1051
Mailing Address - Country:US
Mailing Address - Phone:817-495-1799
Mailing Address - Fax:
Practice Address - Street 1:6244 OBSIDIAN CREEK DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-1544
Practice Address - Country:US
Practice Address - Phone:817-495-1799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 374J00000X
TX134174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No171400000XOther Service ProvidersHealth & Wellness Coach
No374J00000XNursing Service Related ProvidersDoula