Provider Demographics
NPI:1205861119
Name:RUIZ-VAZQUEZ, MIRNA JOANN (LCSW, CASAC)
Entity Type:Individual
Prefix:MS
First Name:MIRNA
Middle Name:JOANN
Last Name:RUIZ-VAZQUEZ
Suffix:
Gender:F
Credentials:LCSW, CASAC
Other - Prefix:MS
Other - First Name:M.
Other - Middle Name:JOANN
Other - Last Name:RUIZ-VAZQUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW, CASAC
Mailing Address - Street 1:181 N PARK DR
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07646-2817
Mailing Address - Country:US
Mailing Address - Phone:201-986-1251
Mailing Address - Fax:201-493-0992
Practice Address - Street 1:65 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3233
Practice Address - Country:US
Practice Address - Phone:201-986-1251
Practice Address - Fax:201-493-0992
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC008420001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P483812OtherLCSW
NJ064277Medicare ID - Type UnspecifiedLCSW