Basic Information
| Provider Information | |||||||||
| NPI: | 1851055818 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUZ | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | BRANDON | ||||||||
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| Credential: | MA, LPCC, LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8170 33RD AVE S # MS 21110Q | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554254516 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9600 UPLAND LN N STE 110 | ||||||||
| Address2: | |||||||||
| City: | MAPLE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553694499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529936200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2021 | ||||||||
| LastUpdateDate: | 11/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 305677 | MN | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 3083 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.