Provider Demographics
NPI:1902212798
Name:DE LA CRUZ, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:DE LA 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:PO BOX 361
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-0361
Mailing Address - Country:US
Mailing Address - Phone:831-917-2413
Mailing Address - Fax:
Practice Address - Street 1:3490 THE ALAMEDA
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-4333
Practice Address - Country:US
Practice Address - Phone:408-243-0222
Practice Address - Fax:408-289-1140
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115663106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist