Provider Demographics
NPI:1073171203
Name:RUIZ, IVELISSE (MA)
Entity Type:Individual
Prefix:MRS
First Name:IVELISSE
Middle Name:
Last Name:RUIZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1383 SHALLCROSS AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-6839
Mailing Address - Country:US
Mailing Address - Phone:787-218-8136
Mailing Address - Fax:
Practice Address - Street 1:6900 S ORANGE BLOSSOM TRL STE 402
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-5734
Practice Address - Country:US
Practice Address - Phone:407-382-9079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17851101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health