Provider Demographics
NPI:1609628502
Name:CRUZ, MICAELA LARES (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:MICAELA
Middle Name:LARES
Last Name:CRUZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MISS
Other - First Name:MICAELA
Other - Middle Name:LARES
Other - Last Name:NIEVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1088
Mailing Address - Country:US
Mailing Address - Phone:631-827-8818
Mailing Address - Fax:
Practice Address - Street 1:1413 STONY BROOK RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2214
Practice Address - Country:US
Practice Address - Phone:631-827-8818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY084300104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker