Provider Demographics
NPI:1275214272
Name:CRUZATA MATOS, IDANIA MARIA
Entity Type:Individual
Prefix:
First Name:IDANIA
Middle Name:MARIA
Last Name:CRUZATA MATOS
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 1:4162 SHEPPARD DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-6852
Mailing Address - Country:US
Mailing Address - Phone:725-910-1550
Mailing Address - Fax:
Practice Address - Street 1:1601 E FLAMINGO RD STE 18
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5244
Practice Address - Country:US
Practice Address - Phone:702-478-9971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician