Provider Demographics
NPI:1639527666
Name:CERVANTES CRUZ, MAYRA
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:CERVANTES 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 1:170 S SPRUCE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-4557
Mailing Address - Country:US
Mailing Address - Phone:415-681-3211
Mailing Address - Fax:
Practice Address - Street 1:1510 FASHION ISLAND BLVD STE 310M
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94404-1587
Practice Address - Country:US
Practice Address - Phone:415-231-4121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X
CA97499104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program