Provider Demographics
NPI:1033607577
Name:RUIZ PUIG, IVELIS
Entity Type:Individual
Prefix:MS
First Name:IVELIS
Middle Name:
Last Name:RUIZ PUIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 SW 78TH CT # 1113
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-4307
Mailing Address - Country:US
Mailing Address - Phone:305-794-1596
Mailing Address - Fax:
Practice Address - Street 1:1113 SW 78TH CT # 1113
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-4307
Practice Address - Country:US
Practice Address - Phone:305-794-1596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-62169106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023022100Medicaid