Provider Demographics
NPI:1760065791
Name:RUIZ, AMANDA KAROL (LMSW)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:KAROL
Last Name:RUIZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 JUSTINE CT
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5861
Mailing Address - Country:US
Mailing Address - Phone:631-833-1451
Mailing Address - Fax:
Practice Address - Street 1:517 JUSTINE CT
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5861
Practice Address - Country:US
Practice Address - Phone:631-833-1451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112492104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY088511OtherLICENSURE
NY112492OtherASWB
NY112492OtherLMSW