Healthcare Provider Details

I. General information

NPI: 1912328071
Provider Name (Legal Business Name): HEATHER LEE RUVOLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2013
Last Update Date: 12/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SPORTFISHER DR
OCEANSIDE CA
92054-2550
US

IV. Provider business mailing address

3513 LONE PINE LN
SAN MARCOS CA
92078-6203
US

V. Phone/Fax

Practice location:
  • Phone: 760-439-6702
  • Fax:
Mailing address:
  • Phone: 760-224-6477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: