Provider Demographics
NPI:1497534689
Name:FAZIO-RUGGIERO, KIMBERLY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:FAZIO-RUGGIERO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 WATERBURY RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-2437
Mailing Address - Country:US
Mailing Address - Phone:908-917-6011
Mailing Address - Fax:
Practice Address - Street 1:FCI OTISVILLE
Practice Address - Street 2:2 MILE DRIVE
Practice Address - City:OTISVILLE
Practice Address - State:NY
Practice Address - Zip Code:10963
Practice Address - Country:US
Practice Address - Phone:845-386-6839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025988103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical