Provider Demographics
NPI:1174687594
Name:CRUZ, LISA (MSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2509
Mailing Address - Country:US
Mailing Address - Phone:360-423-7740
Mailing Address - Fax:360-423-7894
Practice Address - Street 1:1057 12TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2509
Practice Address - Country:US
Practice Address - Phone:360-423-7740
Practice Address - Fax:360-423-7894
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00040850101Y00000X
WALW60141913171M00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator