MEDICARE: MS. MIRNA JOANN RUIZ-VAZQUEZ LCSW, CASAC

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	1041C0700X	Clinical Social Worker	44SC00842000	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P483812	OTHER		LCSW

General Provider Information

NPI Number	:	1205861119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MIRNA JOANN RUIZ-VAZQUEZ LCSW, CASAC

Provider Business Mailing Address
First Line	:	181 N PARK DR
Second Line	:
City	:	NEW MILFORD
State	:	NJ
Zip	:	07646-2817
Country	:	US
Telephone Number	:	201-986-1251
Fax Number	:	201-493-0992

Provider Business Practice Location Address
First Line	:	65 N MAPLE AVE
Second Line	:
City	:	RIDGEWOOD
State	:	NJ
Zip	:	07450-3233
Country	:	US
Telephone Number	:	201-986-1251
Fax Number	:	201-493-0992

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

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	07/08/2007

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