Provider Demographics
NPI:1538779905
Name:CRUZ, KYMBERLY
Entity type:Individual
Prefix:
First Name:KYMBERLY
Middle Name:
Last Name: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 1:1440 N HARBOR BLVD STE 900
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-4122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1440 N HARBOR BLVD STE 900
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4122
Practice Address - Country:US
Practice Address - Phone:714-519-6319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2022-02-07
Deactivation Date:2021-04-06
Deactivation Code:
Reactivation Date:2021-11-28
Provider Licenses
StateLicense IDTaxonomies
CA118563106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist