Provider Demographics
NPI:1689222598
Name:RUIZ, ANGELIA (LAC)
Entity Type:Individual
Prefix:
First Name:ANGELIA
Middle Name:
Last Name:RUIZ
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:ANGELIA
Other - Middle Name:
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 11818
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1818
Mailing Address - Country:US
Mailing Address - Phone:479-452-6650
Mailing Address - Fax:479-452-5847
Practice Address - Street 1:3111 S 70TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5017
Practice Address - Country:US
Practice Address - Phone:479-452-6650
Practice Address - Fax:479-452-5847
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2102215101YM0800X
171M00000X
ARP2311001101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator