Provider Demographics
NPI:1942827951
Name:CRUZAN HOMESTEAD
Entity Type:Organization
Organization Name:CRUZAN HOMESTEAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-244-9410
Mailing Address - Street 1:1734 ROHRERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21758-1129
Mailing Address - Country:US
Mailing Address - Phone:301-244-9410
Mailing Address - Fax:
Practice Address - Street 1:5305 JEFFERSON PIKE STE C7
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-6982
Practice Address - Country:US
Practice Address - Phone:301-244-9410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty