Provider Demographics
NPI:1497391270
Name:CRUZ, CORY BLAKE (PPC)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:BLAKE
Last Name:CRUZ
Suffix:
Gender:M
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 S WILSON ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2941
Mailing Address - Country:US
Mailing Address - Phone:307-256-3791
Mailing Address - Fax:307-265-4480
Practice Address - Street 1:231 S WILSON ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2941
Practice Address - Country:US
Practice Address - Phone:307-256-3791
Practice Address - Fax:307-265-4480
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1161101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional