Healthcare Provider Details

I. General information

NPI: 1861015802
Provider Name (Legal Business Name): LINDA DIANA RUIZ PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 YORK ST
NEW HAVEN CT
06510-3221
US

IV. Provider business mailing address

401 LIGHTHOUSE LN
EAST LYME CT
06333-1774
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-4085
  • Fax: 203-785-3752
Mailing address:
  • Phone: 845-380-4814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number004245
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: