Provider Demographics
NPI:1689285876
Name:DE LA CRUZ, RANDI J
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:J
Last Name:DE LA 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 1:48374 BARBARITA LN
Mailing Address - Street 2:
Mailing Address - City:TICKFAW
Mailing Address - State:LA
Mailing Address - Zip Code:70466-4644
Mailing Address - Country:US
Mailing Address - Phone:985-662-1396
Mailing Address - Fax:
Practice Address - Street 1:1102 COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-5954
Practice Address - Country:US
Practice Address - Phone:985-662-3799
Practice Address - Fax:985-662-3829
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA101YOOOOOXMedicaid