Provider Demographics
NPI:1780964387
Name:CRUZ, IMMANUEL T (OTR)
Entity type:Individual
Prefix:MR
First Name:IMMANUEL
Middle Name:T
Last Name:CRUZ
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 PAPER MILL DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3193
Mailing Address - Country:US
Mailing Address - Phone:404-563-4593
Mailing Address - Fax:770-465-5304
Practice Address - Street 1:2155 W PARK CT
Practice Address - Street 2:SUITE G
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3500
Practice Address - Country:US
Practice Address - Phone:770-465-5084
Practice Address - Fax:770-465-5304
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004739225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist