Provider Demographics
NPI:1376073767
Name:CROSS, HEATHER ELIZABETH
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ELIZABETH
Last Name:CROSS
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 1:1101 BRYAN AVE STE E
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-4401
Mailing Address - Country:US
Mailing Address - Phone:714-352-5800
Mailing Address - Fax:714-352-5801
Practice Address - Street 1:520 N MAIN ST STE 220
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4623
Practice Address - Country:US
Practice Address - Phone:714-543-5609
Practice Address - Fax:714-543-5621
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94023405103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSB94023405OtherLICENSE