Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | MSW007607 | GA |
N | 1041C0700X | Clinical Social Worker | 10882419-3501 | UT |
NPI | 1003354119 |
---|---|
Provider Name | Alisha Delacruz |
First Address | Hill Afb, UT 84056-5012 |
Second Address | Hill Afb, UT 84056-5012 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/02/2017 |
Last Update Date | 29/06/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MSW007607 | LICENSE (01) | GA |