Provider Demographics
NPI:1912294547
Name:RUYLE, CLIFFORD ALLEN JR (LCSW, CGP)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:ALLEN
Last Name:RUYLE
Suffix:JR
Gender:M
Credentials:LCSW, CGP
Other - Prefix:
Other - First Name:C.
Other - Middle Name:ALLEN
Other - Last Name:RUYLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3465 CAMINO DEL RIO S STE 320
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3909
Mailing Address - Country:US
Mailing Address - Phone:619-213-3000
Mailing Address - Fax:866-302-7589
Practice Address - Street 1:3465 CAMINO DEL RIO S STE 320
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3909
Practice Address - Country:US
Practice Address - Phone:619-213-3000
Practice Address - Fax:866-302-7589
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 268091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912294547Medicaid
CA1912294547Medicaid