Provider Demographics
NPI:1790458255
Name:CRUZ, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:CRUZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3419 VALLE VERDE DR
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-2414
Mailing Address - Country:US
Mailing Address - Phone:707-721-2060
Mailing Address - Fax:
Practice Address - Street 1:3419 VALLE VERDE DR
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2414
Practice Address - Country:US
Practice Address - Phone:707-721-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2022-12-09
Deactivation Date:2022-08-14
Deactivation Code:
Reactivation Date:2022-12-08
Provider Licenses
StateLicense IDTaxonomies
106S00000X
HIRBT-22-233967106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician