Healthcare Provider Details

I. General information

NPI: 1295387264
Provider Name (Legal Business Name): STEPHANIE TATIANA RUIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3424 MOTOR AVE STE 101
LOS ANGELES CA
90034-4710
US

IV. Provider business mailing address

1039 W 67TH ST
LOS ANGELES CA
90044-5231
US

V. Phone/Fax

Practice location:
  • Phone: 424-672-6700
  • Fax: 424-672-6819
Mailing address:
  • Phone: 323-482-4885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: