Provider Demographics
NPI:1336923747
Name:DE LA CRUZ, MARY NANCY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:NANCY
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 S CENTRE AVE APT 3D
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-5756
Mailing Address - Country:US
Mailing Address - Phone:516-840-1589
Mailing Address - Fax:
Practice Address - Street 1:6080 JERICHO TPKE STE 200
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2808
Practice Address - Country:US
Practice Address - Phone:631-864-7770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst