=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962516864
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHERINE G RUIZ-MELLOTT M.D.,MPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
Last Update Date | 09/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 76 SUMMER STREET WHITTIER PAVILION
-----------------------------------------------------
City | HAVERHILL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-556-6229
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 SOUTH ST
-----------------------------------------------------
City | JAMAICA PLAIN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02130-3510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-459-9283
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 227275
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------