Provider Demographics
NPI:1538755210
Name:CRUZ, KIMBERLY J (LSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:CRUZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 ILLINOIS AVE.
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2909
Practice Address - Country:US
Practice Address - Phone:937-610-4673
Practice Address - Fax:937-736-2615
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2005705104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker