Provider Demographics
NPI:1336638444
Name:CRUZ, JOHNNY JR
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:CRUZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 E WESTFIELD AVE APT C4
Mailing Address - Street 2:
Mailing Address - City:ROSELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07204-2321
Mailing Address - Country:US
Mailing Address - Phone:917-355-7026
Mailing Address - Fax:
Practice Address - Street 1:2857 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-5126
Practice Address - Country:US
Practice Address - Phone:718-235-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily