Provider Demographics
NPI:1073510111
Name:KRUZICH, DAVID JOHN (PHD, LCSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
Last Name:KRUZICH
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79930-2517
Mailing Address - Country:US
Mailing Address - Phone:915-566-2000
Mailing Address - Fax:915-566-2056
Practice Address - Street 1:4625 ALABAMA ST
Practice Address - Street 2:STE C
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79930-2517
Practice Address - Country:US
Practice Address - Phone:915-566-2000
Practice Address - Fax:915-566-2056
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX004901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R64685Medicare UPIN