MEDICARE: MS. DIANA RUIZ M.A, LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	180009660	IL

General Provider Information

NPI Number	:	1053796870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANA RUIZ M.A, LCPC

Provider Business Mailing Address
First Line	:	701 PIPER LN
Second Line	:
City	:	PROSPECT HEIGHTS
State	:	IL
Zip	:	60070-3613
Country	:	US
Telephone Number	:	847-636-9836
Fax Number	:

Provider Business Practice Location Address
First Line	:	6232 N PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-5132
Country	:	US
Telephone Number	:	312-451-6154
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2015
Last Update Date	:	07/22/2015

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