Healthcare Provider Details

I. General information

NPI: 1497093330
Provider Name (Legal Business Name): EDITA RUZGYTE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2013
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 CANDLEWOOD RD
FORT WORTH TX
76103-1112
US

IV. Provider business mailing address

3001 AVENUE D
FORT WORTH TX
76105-1518
US

V. Phone/Fax

Practice location:
  • Phone: 972-658-5422
  • Fax:
Mailing address:
  • Phone: 972-658-5422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number62048
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: