Provider Demographics
NPI:1003484775
Name:CRUZ CONSTANTINO, DALLAN ALTAVILA (OTR/L)
Entity type:Individual
Prefix:
First Name:DALLAN
Middle Name:ALTAVILA
Last Name:CRUZ CONSTANTINO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 WILDROSE LN APT 116
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-8802
Mailing Address - Country:US
Mailing Address - Phone:956-621-8438
Mailing Address - Fax:
Practice Address - Street 1:77 NORTH EXPY K
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-7852
Practice Address - Country:US
Practice Address - Phone:956-541-2102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121810225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics