Healthcare Provider Details

I. General information

NPI: 1083530703
Provider Name (Legal Business Name): DALLYSSA RUBIERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 GALLERIA COURT DR APT 108
CHARLOTTE NC
28270-2515
US

IV. Provider business mailing address

1535 GALLERIA COURT DR APT 108
CHARLOTTE NC
28270-2515
US

V. Phone/Fax

Practice location:
  • Phone: 646-250-3822
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1203949
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: