Healthcare Provider Details

I. General information

NPI: 1497534689
Provider Name (Legal Business Name): KIMBERLY FAZIO-RUGGIERO PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FCI OTISVILLE 2 MILE DRIVE
OTISVILLE NY
10963
US

IV. Provider business mailing address

2094 ALBANY POST RD BLDG 1
MONTROSE NY
10548-1454
US

V. Phone/Fax

Practice location:
  • Phone: 845-386-6839
  • Fax:
Mailing address:
  • Phone: 914-737-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number025988
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: