Healthcare Provider Details

I. General information

NPI: 1780081547
Provider Name (Legal Business Name): RUARK PSYCHOTHERAPY APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2014
Last Update Date: 11/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CASTLE HEIGHTS AVE
LOS ANGELES CA
90034-2753
US

IV. Provider business mailing address

9854 NATIONAL BLVD SUITE 372
LOS ANGELES CA
90034-2713
US

V. Phone/Fax

Practice location:
  • Phone: 310-837-7979
  • Fax:
Mailing address:
  • Phone: 310-837-7979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY10329
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT34153
License Number StateCA

VIII. Authorized Official

Name: DANIEL RUARK
Title or Position: PRESIDENT
Credential: M.A., M.F.T.
Phone: 310-837-7979