Provider Demographics
NPI:1790166122
Name:CRUZ, KRISILEE KAY (ISAS)
Entity Type:Individual
Prefix:
First Name:KRISILEE
Middle Name:KAY
Last Name:CRUZ
Suffix:
Gender:F
Credentials:ISAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 W BROADWAY ST STE G
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2902
Mailing Address - Country:US
Mailing Address - Phone:208-524-7400
Mailing Address - Fax:208-524-8004
Practice Address - Street 1:2275 W BROADWAY ST STE G
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2902
Practice Address - Country:US
Practice Address - Phone:208-524-7400
Practice Address - Fax:208-524-8004
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10228101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0001256907Medicaid