Provider Demographics
NPI:1659164721
Name:CRUZ CORDERO, DERICK JESUS (PSY D)
Entity type:Individual
Prefix:
First Name:DERICK
Middle Name:JESUS
Last Name:CRUZ CORDERO
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CALLE MALAGUETA
Mailing Address - Street 2:
Mailing Address - City:ISABELA
Mailing Address - State:PR
Mailing Address - Zip Code:00662-3202
Mailing Address - Country:US
Mailing Address - Phone:787-631-8979
Mailing Address - Fax:
Practice Address - Street 1:BARRIO VOLADORADA CARRETERA 111 KM 7.1
Practice Address - Street 2:
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676-9617
Practice Address - Country:US
Practice Address - Phone:787-877-3696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-22
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7783103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR8760535OtherDRIVER'S LICENSE