Provider Demographics
NPI:1689259806
Name:RUIZ, NATHALY JACQUELINE
Entity Type:Individual
Prefix:
First Name:NATHALY
Middle Name:JACQUELINE
Last Name:RUIZ
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 1:4025 CAMINO DEL RIO S STE 207
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4108
Mailing Address - Country:US
Mailing Address - Phone:619-297-5131
Mailing Address - Fax:
Practice Address - Street 1:4025 CAMINO DEL RIO S STE 207
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4108
Practice Address - Country:US
Practice Address - Phone:619-297-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11792101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health