Provider Demographics
NPI:1689123135
Name:CRUZ QUESADA, GERARDO ANTONIO (PHD)
Entity Type:Individual
Prefix:DR
First Name:GERARDO
Middle Name:ANTONIO
Last Name:CRUZ QUESADA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 PASCO RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01151-1933
Mailing Address - Country:US
Mailing Address - Phone:214-502-2726
Mailing Address - Fax:
Practice Address - Street 1:138 PASCO RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01151-1933
Practice Address - Country:US
Practice Address - Phone:214-502-2726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
PR103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health