Provider Demographics
NPI:1497486807
Name:CRUZ MIRANDA, EDGAR ALFONSO (LMFT)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:ALFONSO
Last Name:CRUZ MIRANDA
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2489 TAPO ST STE B
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2453
Mailing Address - Country:US
Mailing Address - Phone:805-774-1506
Mailing Address - Fax:
Practice Address - Street 1:2489 TAPO ST STE B
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-2453
Practice Address - Country:US
Practice Address - Phone:805-774-1506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA131726106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist