Provider Demographics
NPI:1689246746
Name:CRUZ, BREANNA RAQUELLE
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:RAQUELLE
Last Name:CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:RAQUELLE
Other - Last Name:AHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95423-0366
Mailing Address - Country:US
Mailing Address - Phone:707-349-8897
Mailing Address - Fax:
Practice Address - Street 1:14715 HWY 20
Practice Address - Street 2:
Practice Address - City:CLEARLAKE OAKS
Practice Address - State:CA
Practice Address - Zip Code:95423
Practice Address - Country:US
Practice Address - Phone:707-998-1800
Practice Address - Fax:707-998-0122
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)