Provider Demographics
NPI:1144765546
Name:LIFT VITALIZE & RESTORE PSYCHIATRIC SERVICES PLLC
Entity Type:Organization
Organization Name:LIFT VITALIZE & RESTORE PSYCHIATRIC SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:NEDIA
Authorized Official - Middle Name:N
Authorized Official - Last Name:DELUA-RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:361-960-2392
Mailing Address - Street 1:6625 WOOLDRIDGE RD
Mailing Address - Street 2:101
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-2916
Mailing Address - Country:US
Mailing Address - Phone:361-356-6441
Mailing Address - Fax:361-356-6565
Practice Address - Street 1:6625 WOOLDRIDGE RD
Practice Address - Street 2:101
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-2916
Practice Address - Country:US
Practice Address - Phone:361-356-6441
Practice Address - Fax:361-356-6565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132546364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1992247803OtherNPI NUMBER