Provider Demographics
NPI:1295401669
Name:RUIZ, ITZAI ANDREA (OCPSA 161734)
Entity Type:Individual
Prefix:MISS
First Name:ITZAI
Middle Name:ANDREA
Last Name:RUIZ
Suffix:
Gender:F
Credentials:OCPSA 161734
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1138
Mailing Address - Country:US
Mailing Address - Phone:440-989-4900
Mailing Address - Fax:
Practice Address - Street 1:2115 W PARK DR
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1138
Practice Address - Country:US
Practice Address - Phone:440-989-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OH161734405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
No175T00000XOther Service ProvidersPeer Specialist