Provider Demographics
NPI:1528390309
Name:RUOTOLO, JUSTINE M
Entity Type:Individual
Prefix:MISS
First Name:JUSTINE
Middle Name:M
Last Name:RUOTOLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5762 RAVENSPUR DR
Mailing Address - Street 2:APT # 715
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-3570
Mailing Address - Country:US
Mailing Address - Phone:310-735-5874
Mailing Address - Fax:
Practice Address - Street 1:24050 MADISON ST
Practice Address - Street 2:SUITE# 216
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6015
Practice Address - Country:US
Practice Address - Phone:310-735-5874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95105106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist