Provider Demographics
NPI:1073373841
Name:FUNDORA RUIZ, TANIA
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:FUNDORA RUIZ
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 1:2482 IVAN CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-8505
Mailing Address - Country:US
Mailing Address - Phone:407-249-6330
Mailing Address - Fax:407-307-2328
Practice Address - Street 1:5575 S SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-1747
Practice Address - Country:US
Practice Address - Phone:321-442-9923
Practice Address - Fax:407-307-2328
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-324208106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty