Provider Demographics
NPI:1639704919
Name:SANTACRUZ, LISSETTE ALEJANDRA
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:ALEJANDRA
Last Name:SANTACRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISSETTE
Other - Middle Name:ALEJANDRA
Other - Last Name:HUMARAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6640 NADEAU LN
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-1638
Mailing Address - Country:US
Mailing Address - Phone:951-999-7902
Mailing Address - Fax:
Practice Address - Street 1:8350 ARCHIBALD AVE STE 110
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3670
Practice Address - Country:US
Practice Address - Phone:800-434-8923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-07
Last Update Date:2020-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106S00000XMedicaid