Provider Demographics
NPI:1093184012
Name:RUIZ, CHANCEY MARIE (LCDC)
Entity Type:Individual
Prefix:
First Name:CHANCEY
Middle Name:MARIE
Last Name:RUIZ
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 S VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-4344
Mailing Address - Country:US
Mailing Address - Phone:254-965-5515
Mailing Address - Fax:254-965-7416
Practice Address - Street 1:2111 W US HIGHWAY 377
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5627
Practice Address - Country:US
Practice Address - Phone:817-573-6002
Practice Address - Fax:817-573-6009
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13133101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148686201Medicaid