Provider Demographics
NPI:1487080883
Name:RUIZ, ROBERT (MA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:RUIZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2632 SW PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2845
Mailing Address - Country:US
Mailing Address - Phone:561-616-8411
Mailing Address - Fax:
Practice Address - Street 1:2632 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2845
Practice Address - Country:US
Practice Address - Phone:561-616-8411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJS-4169101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health