Provider Demographics
NPI:1013346337
Name:RUIZ, ANTONIO (MA MFT INTERN)
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:
Last Name:RUIZ
Suffix:
Gender:M
Credentials:MA MFT INTERN
Other - Prefix:MR
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:RUIZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA MFT INTERN
Mailing Address - Street 1:10110 LEUCADIA LN
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-1030
Mailing Address - Country:US
Mailing Address - Phone:951-217-5233
Mailing Address - Fax:951-530-1601
Practice Address - Street 1:10110 LEUCADIA LN
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-1030
Practice Address - Country:US
Practice Address - Phone:951-217-5233
Practice Address - Fax:951-530-1601
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA#73702251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management