Provider Demographics
NPI:1295452530
Name:CRUZ HEREDIA, MARIA ROSARIO (AMFT)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:ROSARIO
Last Name:CRUZ HEREDIA
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 MENTONE BLVD SPC 23
Mailing Address - Street 2:
Mailing Address - City:MENTONE
Mailing Address - State:CA
Mailing Address - Zip Code:92359-9645
Mailing Address - Country:US
Mailing Address - Phone:909-709-3089
Mailing Address - Fax:
Practice Address - Street 1:2140 MENTONE BLVD SPC 23
Practice Address - Street 2:
Practice Address - City:MENTONE
Practice Address - State:CA
Practice Address - Zip Code:92359-9645
Practice Address - Country:US
Practice Address - Phone:909-709-3089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT104249103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical