Provider Demographics
NPI:1396209565
Name:CRUZ, ELISA C
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:C
Last Name:CRUZ
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 1:307 MAPLE AVE W STE L
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4307
Mailing Address - Country:US
Mailing Address - Phone:703-672-1613
Mailing Address - Fax:
Practice Address - Street 1:307 MAPLE AVE W STE L
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4307
Practice Address - Country:US
Practice Address - Phone:703-672-1613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019013040225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist