Healthcare Provider Details

I. General information

NPI: 1265189864
Provider Name (Legal Business Name): CAMILLE CRYSTAL RUYBAL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1942 BROADWAY STE 314C
BOULDER CO
80302-5233
US

IV. Provider business mailing address

PO BOX 1222
ALAMOSA CO
81101-1222
US

V. Phone/Fax

Practice location:
  • Phone: 719-580-4330
  • Fax:
Mailing address:
  • Phone: 719-401-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0017811
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: