=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336384718
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GABRIEL RUIZ, LCPC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2008
-----------------------------------------------------
Last Update Date | 12/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 N WABASH AVE SUITE 1319
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-665-0053
-----------------------------------------------------
Fax | 708-231-7541
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 N WABASH AVE SUITE 1319
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-665-0053
-----------------------------------------------------
Fax | 708-231-7541
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND MANAGER
-----------------------------------------------------
Name | MR. GABRIEL RUIZ
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 312-665-0053
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180004827
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------