Provider Demographics
NPI:1982004503
Name:CRUZ, AGUSTIN JOSEPH (MPA, MS, LPC)
Entity Type:Individual
Prefix:MR
First Name:AGUSTIN
Middle Name:JOSEPH
Last Name:CRUZ
Suffix:
Gender:M
Credentials:MPA, MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7825 MIDLOTHIAN TPKE STE 203
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-5247
Mailing Address - Country:US
Mailing Address - Phone:229-412-8125
Mailing Address - Fax:
Practice Address - Street 1:7825 MIDLOTHIAN TPKE STE 203
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-5247
Practice Address - Country:US
Practice Address - Phone:229-412-8125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006356101YP2500X, 101YM0800X, 101Y00000X, 103K00000X
GALPC007933101YS0200X, 102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst