Healthcare Provider Details

I. General information

NPI: 1134406168
Provider Name (Legal Business Name): KRISTINA RUIZ LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37-26 76TH AVENUE
JACKSON HEIGHTS NY
11372
US

IV. Provider business mailing address

98-120 QUEENS BLVD
REGO PARK NY
11374
US

V. Phone/Fax

Practice location:
  • Phone: 718-830-0246
  • Fax: 718-830-9088
Mailing address:
  • Phone: 718-830-0246
  • Fax: 718-830-9088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number004419-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: