Provider Demographics
NPI:1801443585
Name:DE LA CRUZ, EVELYN
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:
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 1:601 S RANCHO DR STE A10
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4898
Mailing Address - Country:US
Mailing Address - Phone:702-437-4673
Mailing Address - Fax:
Practice Address - Street 1:601 S RANCHO DR STE A10
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4898
Practice Address - Country:US
Practice Address - Phone:702-437-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NVCI5054101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-1661683OtherMEDI-CAL