Healthcare Provider Details

I. General information

NPI: 1063227403
Provider Name (Legal Business Name): DIANA PEREZ RUIZ SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2363 S 102ND ST STE 203
WEST ALLIS WI
53227-2143
US

IV. Provider business mailing address

2363 S 102ND ST STE 203
WEST ALLIS WI
53227-2143
US

V. Phone/Fax

Practice location:
  • Phone: 262-447-8999
  • Fax: 262-404-8833
Mailing address:
  • Phone: 262-447-8999
  • Fax: 262-404-8833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19705-130
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9051-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: