Healthcare Provider Details

I. General information

NPI: 1346035854
Provider Name (Legal Business Name): MAXIMILIAN RUIZ DEZARATE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22018 S CENTRAL POINT RD
CANBY OR
97013-8705
US

IV. Provider business mailing address

4017 SE YAMHILL ST
PORTLAND OR
97214-4444
US

V. Phone/Fax

Practice location:
  • Phone: 503-221-4531
  • Fax:
Mailing address:
  • Phone: 484-639-2260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: