Provider Demographics
NPI:1689297624
Name:CRUZ, REBECCA D
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:D
Last Name: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 1:9808 VENICE BLVD STE 700
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-6824
Mailing Address - Country:US
Mailing Address - Phone:310-945-3350
Mailing Address - Fax:310-945-3356
Practice Address - Street 1:840 N AVENUE 66
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-1508
Practice Address - Country:US
Practice Address - Phone:626-395-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40290167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician