Provider Demographics
NPI:1275259574
Name:HARRY, RUSLYN CANDACE (MAT)
Entity Type:Individual
Prefix:MRS
First Name:RUSLYN
Middle Name:CANDACE
Last Name:HARRY
Suffix:
Gender:F
Credentials:MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16317 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3029
Mailing Address - Country:US
Mailing Address - Phone:347-484-1569
Mailing Address - Fax:
Practice Address - Street 1:16317 130TH AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-3029
Practice Address - Country:US
Practice Address - Phone:347-484-1569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1460366211101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Single Specialty