Healthcare Provider Details

I. General information

NPI: 1033306451
Provider Name (Legal Business Name): JANEIL NELLIS RUIZ PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2007
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 W CHICAGO AVE SUITE 302 C
CHICAGO IL
60622-4375
US

IV. Provider business mailing address

1333 N ARTESIAN AVE #2
CHICAGO IL
60622-2935
US

V. Phone/Fax

Practice location:
  • Phone: 773-627-2112
  • Fax:
Mailing address:
  • Phone: 773-627-2112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.008116
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: