Provider Demographics
NPI:1174840128
Name:CRUZ RIVERA, INDIRA VANESSA (LMT)
Entity Type:Individual
Prefix:
First Name:INDIRA
Middle Name:VANESSA
Last Name:CRUZ RIVERA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21737 CORBETT RD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2240
Mailing Address - Country:US
Mailing Address - Phone:718-669-8428
Mailing Address - Fax:
Practice Address - Street 1:211 E 43RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-4707
Practice Address - Country:US
Practice Address - Phone:718-669-8428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022829225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist