Basic Information
| Provider Information | |||||||||
| NPI: | 1053975615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUIZ | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 924 4TH AVE APT 2F | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112322339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6463314737 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 348 13TH ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112156179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187885101 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2019 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 105778 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 105778 | 01 | NY | EDUCATION DEPARTMENT | OTHER |