Healthcare Provider Details

I. General information

NPI: 1194466409
Provider Name (Legal Business Name): MELISSA EILLEEN RUANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2022
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 RESERVOIR DR STE 204-A
SAN DIEGO CA
92120-5134
US

IV. Provider business mailing address

5555 RESERVOIR DR STE 204-A
SAN DIEGO CA
92120-5134
US

V. Phone/Fax

Practice location:
  • Phone: 619-822-1800
  • Fax: 619-839-3872
Mailing address:
  • Phone: 619-822-1800
  • Fax: 619-839-3872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPCC11729
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: