Provider Demographics
NPI:1275066193
Name:CRUZ, ALYSSIA (LCSW)
Entity Type:Individual
Prefix:
First Name:ALYSSIA
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4231 BALBOA AVE # 3010
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5504
Mailing Address - Country:US
Mailing Address - Phone:619-630-9312
Mailing Address - Fax:
Practice Address - Street 1:2245 CHALLENGER WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5418
Practice Address - Country:US
Practice Address - Phone:707-565-4431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83876101Y00000X, 1041C0700X
CA972691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor