Provider Demographics
NPI:1700546991
Name:DELACRUZ, MIRTA (MSED)
Entity Type:Individual
Prefix:
First Name:MIRTA
Middle Name:
Last Name:DELACRUZ
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:MIRTA
Other - Middle Name:
Other - Last Name:DELACRUZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSED
Mailing Address - Street 1:436 EASTERN PKWY APT 3F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-1414
Mailing Address - Country:US
Mailing Address - Phone:609-210-7947
Mailing Address - Fax:
Practice Address - Street 1:44 COURT ST STE 1217
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4410
Practice Address - Country:US
Practice Address - Phone:347-491-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor