Provider Demographics
NPI:1306196456
Name:KISH, RUBY (RN, LCSW)
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:
Last Name:KISH
Suffix:
Gender:F
Credentials:RN, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9343 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-6023
Mailing Address - Country:US
Mailing Address - Phone:904-448-4402
Mailing Address - Fax:
Practice Address - Street 1:10175 FORTUNE PKWY
Practice Address - Street 2:1106
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6746
Practice Address - Country:US
Practice Address - Phone:904-379-5928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 10973101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health