Healthcare Provider Details

I. General information

NPI: 1467781609
Provider Name (Legal Business Name): NANCY G. RUESCHENBERG PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2009
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2386 PLAYA VISTA PLACE
AVILA BEACH CA
93424-2386
US

IV. Provider business mailing address

6215 PLAYA VISTA PLACE P. O. BOX 2386
AVILA BEACH CA
93424-2386
US

V. Phone/Fax

Practice location:
  • Phone: 805-595-7037
  • Fax: 805-595-2703
Mailing address:
  • Phone: 805-595-7037
  • Fax: 805-595-2703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY10198
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY10198
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: