Provider Demographics
NPI:1497231021
Name:CRUZ, BLANCA NYDIA
Entity Type:Individual
Prefix:
First Name:BLANCA
Middle Name:NYDIA
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 1:6417 ODANA RD
Mailing Address - Street 2:STE 5
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719
Mailing Address - Country:US
Mailing Address - Phone:608-268-6530
Mailing Address - Fax:608-709-1744
Practice Address - Street 1:6417 ODANA RD
Practice Address - Street 2:STE 5
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719
Practice Address - Country:US
Practice Address - Phone:608-268-6530
Practice Address - Fax:608-709-1744
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3001001516101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool