Healthcare Provider Details

I. General information

NPI: 1376154393
Provider Name (Legal Business Name): TIAYA BLUE RUGGIRELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIAYA BLUE RUGGIRELLO RBT

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13-3773 ALA ILI RD
PAHOA HI
96778-2067
US

IV. Provider business mailing address

PO BOX 2067
PAHOA HI
96778-2067
US

V. Phone/Fax

Practice location:
  • Phone: 907-314-3668
  • Fax:
Mailing address:
  • Phone: 907-314-3668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: