Provider Demographics
NPI:1386469427
Name:RUIZ, MARIO (PMHNP)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:RUIZ
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 W WEST COVINA PKWY # 477
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2810
Mailing Address - Country:US
Mailing Address - Phone:323-947-1167
Mailing Address - Fax:
Practice Address - Street 1:1004 W WEST COVINA PKWY # 477
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2810
Practice Address - Country:US
Practice Address - Phone:626-597-8670
Practice Address - Fax:626-608-0501
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-21
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95030403363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health