Provider Demographics
NPI:1376007211
Name:RUIZ, KATRINA SIMONE
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:SIMONE
Last Name:RUIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:SIMONE
Other - Last Name:RUIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7351 W CHARLESTON BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-1572
Mailing Address - Country:US
Mailing Address - Phone:702-470-0620
Mailing Address - Fax:
Practice Address - Street 1:7351 W CHARLESTON BLVD STE 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-1572
Practice Address - Country:US
Practice Address - Phone:702-470-0620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF5540252106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician