Provider Demographics
NPI:1851601017
Name:DE LA CRUZ, JOHAAN (MA)
Entity Type:Individual
Prefix:
First Name:JOHAAN
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 CALLE DR BASORA N
Mailing Address - Street 2:EDF. MEDICO IV OF. 201
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680-4810
Mailing Address - Country:US
Mailing Address - Phone:787-265-5583
Mailing Address - Fax:787-265-8145
Practice Address - Street 1:55 CALLE DR BASORA N
Practice Address - Street 2:EDF. MEDICO IV OF. 201
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-4810
Practice Address - Country:US
Practice Address - Phone:787-265-5583
Practice Address - Fax:787-265-8145
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3459103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR3459OtherPSICHOLOGIST LICENT