Provider Demographics
NPI:1972163772
Name:RUIZ, NELLISA TAMARIS (OTR/L)
Entity type:Individual
Prefix:MISS
First Name:NELLISA
Middle Name:TAMARIS
Last Name:RUIZ
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 GIFFORD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465-1814
Mailing Address - Country:US
Mailing Address - Phone:347-867-6423
Mailing Address - Fax:
Practice Address - Street 1:1887 BATHGATE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-6216
Practice Address - Country:US
Practice Address - Phone:718-466-3580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023634225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist