Basic Information
| Provider Information | |||||||||
| NPI: | 1306455175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUZ | ||||||||
| FirstName: | ADRIENNE CELINE | ||||||||
| MiddleName: | SAN DIEGO | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PASMAN | ||||||||
| OtherFirstName: | ADRIENNE CELINE | ||||||||
| OtherMiddleName: | CRUZ | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S. CCC-SLP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4071 POND RUN CT | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481882179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349687157 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 161 S WAKEA AVE | ||||||||
| Address2: | |||||||||
| City: | KAHULUI | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967321343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082447467 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2020 | ||||||||
| LastUpdateDate: | 07/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 1869 | HI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.