Healthcare Provider Details

I. General information

NPI: 1386352581
Provider Name (Legal Business Name): JONATHAN GEORGE RUFFUS PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 RUTLAND LN
MELVILLE NY
11747-2614
US

IV. Provider business mailing address

12 RUTLAND LN
MELVILLE NY
11747-2614
US

V. Phone/Fax

Practice location:
  • Phone: 347-439-5264
  • Fax:
Mailing address:
  • Phone: 347-439-5264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number025347
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number025347
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number025347
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: