Provider Demographics
NPI:1376154393
Name:RUGGIRELLO, TIAYA BLUE
Entity Type:Individual
Prefix:
First Name:TIAYA
Middle Name:BLUE
Last Name:RUGGIRELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIAYA
Other - Middle Name:BLUE
Other - Last Name:RUGGIRELLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RBT
Mailing Address - Street 1:PO BOX 2067
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778-2067
Mailing Address - Country:US
Mailing Address - Phone:907-314-3668
Mailing Address - Fax:
Practice Address - Street 1:13-3773 ALA ILI RD
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778-2067
Practice Address - Country:US
Practice Address - Phone:907-314-3668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI9073143668Medicaid