Provider Demographics
NPI:1104361245
Name:CRUZ, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
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 1:7419 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-5734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:703 PLACID LAKE LN
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-5276
Practice Address - Country:US
Practice Address - Phone:346-248-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3047103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst