Provider Demographics
NPI:1609377043
Name:DE LA CRUZ, EDNA (COTA)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-2696
Mailing Address - Country:US
Mailing Address - Phone:956-212-0328
Mailing Address - Fax:
Practice Address - Street 1:1110 S STEWART RD STE D
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-5168
Practice Address - Country:US
Practice Address - Phone:956-283-7555
Practice Address - Fax:956-283-7557
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212279224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX212279OtherTEXAS BOARD OF OCCUPATIONAL THERAPY EXAMINERS