Provider Demographics
NPI:1750706313
Name:DELACRUZ, JOSE (CADC-II)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:DELACRUZ
Suffix:
Gender:M
Credentials:CADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742531
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-1345
Mailing Address - Country:US
Mailing Address - Phone:678-913-3255
Mailing Address - Fax:404-975-4376
Practice Address - Street 1:1990 OLD PARKER RD SE
Practice Address - Street 2:SUITE 100
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6239
Practice Address - Country:US
Practice Address - Phone:678-913-3255
Practice Address - Fax:404-975-4376
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA478101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)