Provider Demographics
NPI:1669418554
Name:RUIZ, MARK DAVID (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:RUIZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11211 TAYLOR DRAPER LN
Mailing Address - Street 2:SUITE 202
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-3916
Mailing Address - Country:US
Mailing Address - Phone:512-343-8850
Mailing Address - Fax:512-343-8079
Practice Address - Street 1:11211 TAYLOR DRAPER LN
Practice Address - Street 2:SUITE 202
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-3916
Practice Address - Country:US
Practice Address - Phone:512-343-8850
Practice Address - Fax:512-343-8079
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX32858103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX079974401Medicaid
TX079974401Medicaid