Provider Demographics
NPI:1144665183
Name:CRUZ, FERNANDO (CADC 1)
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:CRUZ
Suffix:
Gender:M
Credentials:CADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:976 LENZEN AVE
Mailing Address - Street 2:ROOM 1900
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-2737
Mailing Address - Country:US
Mailing Address - Phone:408-792-5652
Mailing Address - Fax:408-947-8719
Practice Address - Street 1:976 LENZEN AVE
Practice Address - Street 2:ROOM 1900
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-2737
Practice Address - Country:US
Practice Address - Phone:408-792-5652
Practice Address - Fax:408-947-8719
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC 4650711101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)