Healthcare Provider Details

I. General information

NPI: 1629844261
Provider Name (Legal Business Name): MRS. RUTH KATYNA JEUDY TARO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 11/27/2023
Certification Date: 11/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 PARK AVE
HUNTINGTON NY
11743-4516
US

IV. Provider business mailing address

22 6TH AVE
HOLBROOK NY
11741-1406
US

V. Phone/Fax

Practice location:
  • Phone: 631-427-3700
  • Fax:
Mailing address:
  • Phone: 631-356-0104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberNA
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: