Provider Demographics
NPI:1740761675
Name:RUIZ, ANDRES J
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:J
Last Name:RUIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 W IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-4904
Mailing Address - Country:US
Mailing Address - Phone:323-667-8843
Mailing Address - Fax:
Practice Address - Street 1:ST. JOSEPH CENTER
Practice Address - Street 2:204 HAMPTON DRIVE
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291
Practice Address - Country:US
Practice Address - Phone:310-396-6468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT107557106H00000X
CA135430106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist