Provider Demographics
NPI:1043875248
Name:DE LA CRUZ, MAXIMO (QMHP-A-MA)
Entity type:Individual
Prefix:MR
First Name:MAXIMO
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:M
Credentials:QMHP-A-MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 ONTELL CT
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-1566
Mailing Address - Country:US
Mailing Address - Phone:571-572-0050
Mailing Address - Fax:888-315-4281
Practice Address - Street 1:7530 DIPLOMAT DR STE 101
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2682
Practice Address - Country:US
Practice Address - Phone:571-572-0050
Practice Address - Fax:888-315-4281
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3329261QM0855X
VA3329-05-001261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAA61348160OtherDL