Provider Demographics
NPI:1548041114
Name:RUIZ VELASCO, JOHANNA GUADALUPE
Entity type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:GUADALUPE
Last Name:RUIZ VELASCO
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JOHANNA
Other - Middle Name:GUADALUPE
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:306 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2941
Mailing Address - Country:US
Mailing Address - Phone:209-478-4554
Mailing Address - Fax:
Practice Address - Street 1:306 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2941
Practice Address - Country:US
Practice Address - Phone:209-478-4554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA1223531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No172V00000XOther Service ProvidersCommunity Health Worker