Provider Demographics
NPI:1871974881
Name:RUIZ, EDGARDO
Entity type:Individual
Prefix:
First Name:EDGARDO
Middle Name:
Last Name:RUIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3137 ROBBINS AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-3114
Mailing Address - Country:US
Mailing Address - Phone:267-338-9944
Mailing Address - Fax:
Practice Address - Street 1:2112 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33406-7670
Practice Address - Country:US
Practice Address - Phone:561-653-6292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA25 248 889101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health