Healthcare Provider Details

I. General information

NPI: 1255255261
Provider Name (Legal Business Name): AMBER RAQUEL RUA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12811 KENWOOD LN STE 213
FORT MYERS FL
33907-5648
US

IV. Provider business mailing address

3244 NW 45TH PL
CAPE CORAL FL
33993-7903
US

V. Phone/Fax

Practice location:
  • Phone: 239-537-9646
  • Fax:
Mailing address:
  • Phone: 732-718-9434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: